NATIONAL HEALTH ACCOUNTS FY 2008/09 and FY 2009/10health.go.ug/docs/NHA_REPORT_FINAL_13.pdfthe...

THE REPUBLIC OF UGANDA

NATIONAL HEALTH ACCOUNTS FY 2008/09 and FY 2009/10

TRACKING RESOURCE FLOWS IN THE HEALTH SYSTEM IN UGANDA FOR THE FINANCIAL YEAR 2008/09 AND FINANCIAL YEAR 2009/10 UGANDA

MARCH

2013

MINISTRY OF HEALTH

General Health Accounts, Reproductive Health sub‐accounts, and Child Health

sub‐accounts

Disclaimer The Uganda NHA technical teams views expressed in this publication do not necessarily reflect the views of the Health Development partners in Uganda. The Ministry of Health shall accept no liability for the consequences of this report being used for a purpose other than those for which the report was commissioned. This report is based on information supplied by respondents; Ministry of Health accepts no liability stemming from any conclusions based on data supplied by respondents other than Ministry of Health.

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NATIONAL HEALTH ACCOUNTS (NHA) CORE TEAM

1. Tom Aliti Candia

Principal Finance Officer/Focal Coordinator – NHA (Uganda) Ministry of Health P.O. Box 7272 Kampala, Uganda Tel: +256 772574789 E‐mail: [email protected]

2. Dr. Jennifer Wanyana

Assistant Commissioner (Reproductive Health) Ministry of Health P.O. Box 7272 Kampala, Uganda Tel: +256772414842 E‐mail: [email protected]

3. Kamya Eriya

Accounts Officer/Programmes Administrator Action Group for Health, Human Rights & HIV/AIDS (AGHA) Uganda P.O. Box 24667 Kampala, Uganda Tel: +256 414348491 Cell: +256 712338505/0758035028 E‐mail:[email protected]/[email protected]

4. Caroline Kyozira

Principal Biostatistician, Resource Centre Ministry of Health P.O. Box 7272 Kampala, Uganda Tel: 256 772863712 E‐mail: [email protected]

5. Sylvester Mubiru

Senior Economist/Assistant Focal Person NHA Uganda Ministry of Health P.O. Box 7272 Kampala, Uganda Cell: +256 772335656 E‐mail: [email protected]

6. Atim Christine Omoding

Senior Internal Auditor Ministry of Health P.O. Box 7272 Kampala, Uganda Cell: +256 772473980 E‐mail: [email protected]

7. Angida Teddy Senior Health Statistician Mulago Hospital P.O. Box 7051 Kampala, Uganda Cell No.+256774776410 E‐mail: [email protected]

8. Walimbwa Aliyi

Senior Health Planner Ministry of Health P.O. Box 7272 Kampala, Uganda Cell: +256 712447241 Fax: +256 414 321572 E‐mail: [email protected]

9. Dr. Timothy Musila

Senior Health Planner Ministry of Health P.O. Box 7272 Kampala, Uganda Cell: +256 701410323 E‐mail: [email protected]

10. Mr. James Mugisha

Senior Health Planner Ministry of Health P.O. Box 7272 Kampala, Uganda Cell: +256 772517281 Fax: +256 321572 E‐mail: [email protected]

11. Bakirese Billbest

Health Planner Mulago Hospital P.O. Box 7051 Kampala, Uganda Tel: +256 414532377 Cell: +256 712353653/+256774743923 Fax: +256 414 532377 E‐mail: [email protected]/[email protected]

12. Patrick Tutembe Economist Ministry of Health Plot 7, Lourdel Road P.O. Box 7272 Kampala, Uganda Tel: +256 712681125 E‐mail: [email protected]

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13. Nantumbwe Brenda Economist, Infrastructure and Social Services Department Ministry of Finance, Planning and Economic Development Finance Building, Apollo Kaggwa Road P.O. Box 8147 Kampala, Uganda

Tel: +256 414 707196 Fax: +256 414230163 Cell: +256 712522388 E‐mail:[email protected]

14. Nassuna Olivia Economist Butabika National Referral Hospital P.O. Box 7017 Uganda Tel: +256 41504388 Fax: +256 41504760 Cell: +256 712425212/+256 703540495 E‐mail: [email protected]

15. Rwakinanga Ezrah Trevor Economist Mulago Hospital P.O. Box 5061 Kampala, Uganda Cell: +256 774227933 Email: [email protected]

16. Hamiidu Katikajjiira‐ Senior Statistician‐ UBOS

17. MR. Ahimbisibwe Expenditus‐ Planner Mulago Hospital

18. Mr. Rogers Enyaku‐ Assistant Commissioner Budget and Finance ‐MOH

19. Dr. Primo Madra‐ UNFPA

20. Dr Jesca Nsubgwa‐ ACHS ( CH) Technical Assistants. 1. Dr Juliet Nabyonga‐ WHO Country office

–Uganda 2. Dr Fred Mugisha‐ Senior Macro

Economics Consultant‐ Ministry of Finance, Planning and Economic Development

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List of tables Table 1: Health outcomes and disease profile .......................................................................... 3 Table 2: leading causes of mortality and morbidity .................................................................. 4 Table 3: Determining the sample size for local governments ................................................. 12 Table 4: Details of selected local governments from each region .......................................... 12 Table 5: The sample for general hospitals to be surveys is derived as follows ....................... 13 Table 6: The sample of private firms to be surveyed .............................................................. 16 Table 7: Summary statistics: NHA General Health Expenditure .............................................. 18 Table 8: Regional Comparison ‐ Total Expenditure on Health and Health Outcomes…………..20 Table 9: Financing sources – General health 2008/09 and 2009/10 ....................................... 21 Table 10: Percent Sector Allocation of government of Uganda funds excluding donors……..21 Table 11: Private sources of funds…………………………………………………………………………………….. 22 Table 12: Rest of the World sources of funds……………………………………………………………………..22 Table 13: Comparison of First, Second, Third and Fourth rounds of NHA Health spending in Uganda ‐ UGX Billions .............................................................................................................. 23 Table 14: Expenditure by financing agents ‐ 2008/9 ‐ 2009/10 .............................................. 23 Table 15: Details of transfers through the different financing agents .................................... 24 Table 16: Expenditure by level of care 2008/09 ‐ 2009/10 ..................................................... 26 Table 17: Expenditure against the different functions ‐ 2008/09 AND 2009/10 .................... 27 Table 18: OOP per capita expenditure on health .................................................................... 28 Table 19: Summary Statistics for Reproductive Health subaccount Expenditures ................. 36 Table 20: Financing sources – RH FYs 2008/09 – 2009/10 ...................................................... 38 Table 21: Financing agents for RH expenditures FYs 2008/09 – 2009/10 ............................... 38 Table 22: Transfers through financing agents ......................................................................... 39 Table 23: Expenditure by level of care FY2008/09 ‐ 2009/10 ................................................. 42 Table 24: Reproductive Health expenditure by function FY2008/9 &2009/10 ....................... 42 Table 25: Summary Statistics for Child Health sub‐account expenditures ............................. 46 Table 26: Sources of financing for Child Health FY 2008/09 ‐ 2009/10………………………………..47 Table 27: Financing agents for CH expenditures – FYs 2008/09 – 2009/10 ............................ 48 Table 28: Detailed transfers through financing agents: ......................................................... 49 Table 29: Child Health expenditures by level of care FY2008/09 ‐ 2009/10 ........................... 51 Table 30: Child Health Expenditure by functions FYs 2008/9 ‐2009/10 ................................. 51

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List of figures Figure 1: Percentage expenditures through the different Financing agents .......................... 24 Figure 2: Detailed breakdown of expenditures through financing agents – FY 2008/9 .......... 25 Figure 3: Detailed breakdown of expenditures through financing agents – FY 2009/10........ 26 Figure 4: Percentage expenditure against the different functions ‐ 2008/09 and 2009/10 ... 27 Figure 5: Average household expenditure by quintiles ........................................................... 28 Figure 6: Total household expenditure by Service provider.................................................... 29 Figure 7: Total household expenditure by service paid for ..................................................... 30 Figure 8: Average household expenditure by regions ............................................................. 31 Figure 9: Financing agents for RH expenditures FYs 2008/09 – 2009/10 ................................ 39 Figure 10: Management of funds spent on RH – FY 2008/9.................................................... 40 Figure 11: Management of funds spent on RH – FY 2009/10 ................................................. 42 Figure 12: Uganda Child Mortality Estimates .......................................................................... 46 Figure 13: Financing agents for CH expenditures – FYs 2008/09 – 2009/10 ........................... 49 Figure 14: Detailed transfers through financing agents 2008/09 ........................................... 50 Figure 15: Detailed transfers through financing agents 2009/10 ........................................... 51 Figure 16: Child Health Expenditure by functions FYs 2008/9 ‐2009/10 ................................ 53

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Acronyms AHC Ambulatory Health Care NHA National Health Accounts

AIDS Acquired Immune Deficiency NHIS National Health Insurance Scheme

ASMC Ancillary Services to Medical Care OECD Organization of Economic Corporation

ATP Alternative or Traditional OOP Out‐of‐Pocket Expenditure

CSOs Civil Society Organizations PATHS 2 Partnership For Transforming Health Systems 2

CWIQS Core Welfare Indicator PHC Primary Health Care

DFID Department for International RH Reproductive Health

ENSK Expenditure Not Specified Kind SHA System of Health Accounts

MOH Ministry of Health MOH Ministry of Health

GDP Gross Domestic Product TB Tuberculosis

GGE General Government Expenditure THE Total Health Expenditure

GGHE General Government Health UNAIDS United Nation Aids

GHS General Household Survey UNFPA United Nation Fund for Population Activities

HIV Human Immunodeficiency Virus USAID United States Agency for International

HMBs Health Management Boards WHO World Health Organisation

HMN Health Metrics Network CHE Current health expenditure

HMOs Health Maintenance GoU Government of Uganda

ICHA International Classification for Health Accounts

MoLG Ministry of Local Government

IMNCH Integrated, Maternal, Newborn and Child Health

PHP Private Health Providers

LG Local Government PNFP Private Not for Profit

LGA Local Government Act IGA Income Generating Activities

LGHE Local Government Health Expenditure

UCMB Uganda Catholic Medical Bureau

MDAs Ministries, Departments and Agencies

UPMB Uganda Protestant Medical Bureau

MDGs Millennium Development Goals UMMB Uganda Muslim Medical Bureau

UAC Uganda Aids Commission GHI Global Health Initiatives

NASA National Aids Spending UGX Uganda shillings

UBOS Uganda Bureau of Statistics OOP Out of pocket contributions

UDHS Uganda Demographic and Health US$: United states dollars

NGO Non‐Governmental Organisation PER Public Expenditure review

FB Facility Based AHSPR Annual Health Sector Performance Report

NFB Non Facility Based

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Foreword Most health sector policy issues facing most African Countries relate to health care financing. Key questions that require answers include: how much resources are flowing into the health sector? Is it adequate to meet the national strategic goals? How can additional resources be mobilized? How can we prioritise investments given available resources? And what is the appropriate mix of financing mechanism to finance universal access to a minimum health care package? Additional questions include: who is managing most of the health care finances? What are the services being provided using available resources? And who are the beneficiaries? National Health Accounts (NHA) is a useful tool for understanding and informing responses to most of these health sector policy issues. Resource tracking through institutionalization of NHA is a global agenda in monitoring Health care financing. Prior to NHA studies, there were a number of attempts by partners and key stakeholders to estimate health expenditure through studies, surveys and public expenditure reviews. However these were generated without a standard approach. The NHA report produced using systems of health accounts is the systematic, comprehensive, and consistent method of monitoring and tracking of resource flows and amounts into a country’s health system. It is a tool specifically designed to inform the health policy processes, including policy design, implementation and policy dialogue. The Ministry of Health (MOH) recognizes the importance of availability of quality data on Health care financing in order to inform development of good financing policies. Uganda’s commitment to Institutionalize NHA dates back to 1997/1998 on the notion that regular preparation of NHA helps policy formulation and evidence based decision making in the health sector. The NHA has impacted policy in many respects. For instance, it has served as basis for advocating for increased for government spending in health, and informed resource allocation decisions in government. It has also informed civil society advocacy efforts, fostered the need for greater coordination, enabled the monitoring of progress towards spending goals, and highlighted weaknesses in the health systems. Government has worked in consultation with other development partners to put appropriate health systems in place and to prepare NHA on a regular basis. This report has been prepared in fulfilment of the Government’s commitment to regularly compile NHA. The MOH has used the NHA framework to produce estimates for National Health Accounts (NHA), Reproductive Health Sub Account (RH) and Child Health Sub Account (CH) for the financial year 2009/09 and 2009/10. The NHA findings will be relevant in development of the health financing strategy for Uganda. I would like to put on record our sincere appreciation and gratitude to WHO, The World Bank, UNICEF, UNFPA, ECSA and USAID for the continued support extended to the Ministry

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of Health in preparation of this NHA report and in our efforts to institutionalize NHA in Uganda. It is my sincere hope that the health sector stakeholders would use the NHA findings to refocus their resources to cost effective interventions in line with our health sector strategic investment plan so that we accelerate our pace to achieving the MDGs. All stakeholders should join hands in ensuring that the objectives of compiling the NHA for FY 2008/09, 2009/10 are fully realized. The findings should also encourage further research into Uganda’s health care financing, leading to a better understanding of the challenges facing the health sector while identifying areas in need of government reform.

Hon. Dr. Christine J.D. Ondoa Minister of Health

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Acknowledgements The production of Uganda’s fourth Round of National Health Accounts (NHA) report for Financial Year 2008/09 and 2009/10, together with the sub accounts for Reproductive Health (RH), and Child Health (CH), is a result of efforts from many partners and institutions. The estimates are based on data collected by Ministry of Health (MOH), Department of Planning in collaboration with other national level institutions and Non‐Governmental Organizations. Data was collected from sampled; public institutions, private firms, donors, Non‐Government Organizations, Health insurance firms and other agencies. Data on household expenditure was extracted from the Uganda National Household Survey of 2009/10 conducted by the Uganda Bureau of Statistics. The Government of Uganda applauds the collaboration of partners and the NHA country team. In addition, the Ministry of Health appreciates the support and technical input of its development partners and NGOs. Specifically the Ministry of Health appreciates the financial and technical support provided by UNICEF, USAID’s Health Systems 20/20 project, WHO, World Bank and ECSA. The constant support provided by UBOS, Mr. Munguti Nzoya from MOPH‐Nairobi, Dr. Juliet Nabyonga of WHO, Dr. Primo Madra of UNFPA, Mr. Jun Fan of UNICEF, Mr. Parani N. and team of USAID‐Uganda, Mr. Edward Kataika and team from ECSA, Dr. Frederick Mugisha of MOFPED‐Kampala and the core NHA technical team of Ministry of Health is greatly appreciated. The Ministry of Health thanks USAID Country office – Uganda, UNFPA, Italian Cooperation, UNICEF Country office and all other HDPs for the invaluable input during the study process especially in mobilizing their implementing partners (Financing Agents). The Ministry of Health recognizes all respondents from Government institutions, NGOs, Insurance firms, Donors, private firms, Not for Profit Providers and community health insurance schemes for their cooperation without which the questionnaires would not have been adequately completed. Finally, undertaking NHA estimation is a process that must constantly be improved by all stakeholders. Users of the NHA report for the two years are therefore invited to freely make comments on the processes, formats of data collection and results as this could reveal areas of improvement in the fifth round of NHA in Uganda.

Dr. Jane Ruth Aceng Director General Health Services Minister of Health

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Executive summary Sustainable and equitable health financing systems play a critical role in improving health outcomes. However such policies must be built on foundation of sound evidence and analyses. The National Health Accounts (NHA) is a tool that helps countries to clearly visualize the flow and use of funds through the health sector, thus contributing to evidence based health policy decision making. The overall objective of the fourth round of NHA in Uganda was to track the amounts and flows of financial resources into the health system in Uganda for financial years 2008/09 and 2009/10 and, respond to key health financing policy questions within the health sector. The study examines Uganda’s Total Health Expenditure for FY2008/09 and FY2009/10, focusing on funding of health sector, management of the financial resources, and their dissemination to General Health, Reproductive Health and Child Health expenditures. It therefore provides a synthesis of findings intended to help policy makers formulate and design a comprehensive health financing strategy. Uganda’s THE increased from 2,809 billion UGX ($1.5 billion) in FY2008/9 to 3,235 billion UGX ($1.6 billion) in FY2009/10. This increase is reflected both in per capita terms as well as percentage of GDP. Private funds from households, PNFPs, local NGOs and private firms made up half of THE(50%, 2008/9 and 49%, 2009/10), while public funds made up only 16%, 2008/9 and 15% 2009/10.Households however accounted for the largest proportion of funds spent on health. Other funds came from donors, international NGOs and Global Health Initiatives making up 34%, 2008/9 and 36%, 2009/10. Funding from donors and Global Health Initiatives showed a significant increase in 2009/10 while that from international NGOs declined. Out‐of‐Pocket (OOP) payments remain the largest form of payment within Uganda’s health sector despite the large flow of donor funds into the country, government’s funding of services within public health facilities and subsidizing of health services at PNFPs. Household managed around 40% of Total Health Expenditure in the two years of study. High OOP payments have fostered inequities in access and utilization health care services as well as general health. Households with limited financial resources find it harder to make health care seeking decisions. The public sector which includes central government and district level managed only 25% of total funds spent on health in 2008/9 and 22% in 2009/10. This limits the ability of government in determining priority areas in which funds should be allocated in order to improve the country’s health indicators. Most health service delivery within Uganda takes place at the district level, therefore control of health funds and priority setting is important

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at this level as health needs vary per district. However, district health services managed on average 7% of funds for Total Health Expenditure in the two years. Utilization of health services at lower level units (HCs II,II and IV)increased by 4% for Reproductive Health, showed a very slight increase(1%) for General Health and a large decline of 1% for Child Health. Health service utilization at hospital level declined for both General Health and Child Health and only showed a 1% increase for Reproductive Health. Utilization of Reproductive Health services by providers other than hospital or lower level units declined by 5% for Reproductive Health but however increased for Child Health and General Health services. Expenditures on Curative functions remain extremely high especially for Reproductive Health, Child Health and General Health services in order of significance. This deviates from the strategies and targets set within the Health Sector Strategic Investment Plan (HSSIP, 2010). Investing in prevention programmes and services is considered a more cost‐effective way of health spending as it reduces burden of disease, improves quality of life and productivity of the general population. Refocusing and evaluating of progress on set strategies and targets is therefore crucial for Uganda to achieve the MDGs by 2015. Key policy issues identified were Public Health Expenditure (PHE) as percentage of Total health expenditure (THE) was still far below the recommended 15% in the Abuja declaration and was lowest among other countries in the region. Government needs to explore alternative financing mechanism to increase resources for health sector, reduce dependency on donors, improve resource allocation criteria to address inequities, build a better link with the private sector and better coordination of partners to attain policy goals and improvement of accounting systems.

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Table of Contents 1. BACKGROUND ....................................................................................................... 2 1.1 Introduction ................................................................................................................. 2

1.2 Health Status in Uganda .............................................................................................. 3

1.2.1 Health outcomes: ................................................................................................. 3

1.2.2 Purpose of NHA and its sub‐accounts.................................................................. 4

1.2.3 Health Financing Policy Issues ............................................................................. 4

Staff accommodation: Kabale hospital Nurses hostel almost complete. ............................. 5

1.3 NHA Entities in Uganda ............................................................................................... 6

1.3.1 Sources ................................................................................................................. 6

1.3.2 Financing Intermediaries ..................................................................................... 7

1.3.3 Providers .............................................................................................................. 8

2. METHODOLOGY .................................................................................................. 10 2.1 Sampling and data collection methods ..................................................................... 10

2.1.1 Introduction ....................................................................................................... 10

2.1.2 Government agencies/institutions .................................................................... 10

2.1.3 Private firms: ...................................................................................................... 15

2.1.4 Private Health Insurance .................................................................................... 16

2.2 Estimation of Household out‐of‐pocket expenditure ............................................... 16

3. RESULTS: General Health Accounts ...................................................................... 18 3.1 Total health expenditure .......................................................................................... 18

3.2 Financing sources: Who pays for Health Care? ......................................................... 20

3.3 Total general government health expenditure (TGGHE) .......................................... 21

3.4 Private sources of financing ...................................................................................... 22

3.5 Rest of the world ....................................................................................................... 22

3.6 Comparison with Previous rounds of NHA ................................................................ 23

3.7 Financing Agents:(Who manages Health Funds?) .................................................... 23

3.8 Health providers: (Who uses Health Funds to deliver Health Care?) ...................... 26

3.9 Health functions: (What services and products are purchased with Health Care Funds?) ................................................................................................................................. 27

3.10 Household OOP expenditure on health .................................................................... 27

4. Conclusions and recommendations ......................................................................... 32 4.1 Overall Health Spending ............................................................................................ 32

4.2 Recommendations .................................................................................................... 32

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5. Reproductive Health Sub-accounts ......................................................................... 34 5.1 Introduction ............................................................................................................... 34

5.2 Policy‐related use of the Reproductive Health sub‐account .................................... 34

5.3 RESULTS: Reproductive Health Sub‐Accounts .......................................................... 37

5.3.1 Financing sources: Who pays for Reproductive Health Care? ........................... 38

5.3.2 Financing Agents: (Who manages Reproductive Health Funds?) ...................... 39

5.4 Reproductive Health expenditure by providers: ....................................................... 43

5.5 Reproductive Health expenditure by functions: (What RH services are purchased with RH Funds?) ................................................................................................................... 43

5.6 Conclusions ................................................................................................................ 44

5.7 Recommendations .................................................................................................... 44

6. Child health sub-accounts ....................................................................................... 46 6.1 Introduction ............................................................................................................... 46

6.2 Results: Child Health Sub‐Accounts .......................................................................... 47

6.3 Financing Sources of Child Health Care: Who Pays for Child Health Services? ........ 48

6.4 Child Health Expenditure by Providers: Who Uses Child Health Funds To Deliver Care? 52

6.5 Child Health Expenditure by Function: What Services Are Purchased With Child Health Funds? ....................................................................................................................... 52

6.6 Conclusions and recommendations .......................................................................... 53

6.6.1 Conclusions ........................................................................................................ 53

6.6.2 Recommendations ............................................................................................. 53

• Need to increase government investment in CH services ........................................ 53

• Address the decline in the share of the provision of prevention and public health programs by increasing focus on preventive health care ................................................ 53

7. Limitations of the Study ........................................................................................... 54 8. Bibliography ............................................................................................................. 55 9. ANNEXES 58

General National Health Accounts

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1. BACKGROUND

1.1 Introduction National Health Accounts (NHA) NHA is an internationally accepted methodology used to determine a nation’s total health expenditure patterns, including public, private, and donor spending. NHA methodology tracks the flow of health funds from a specific source (where the money comes from), to its specific intermediary (who manages the money, who makes allocation decisions), to its specific end use (services provided). Health Expenditure Health expenditures are defined on the basis of their primary purpose, regardless of the primary function or activity of the entity providing or paying for the associated health services. Health expenditures are defined as all expenditures or outlays for prevention, promotion, rehabilitation, and care; population activities; nutrition and emergency programs for the specific and predominant objective of improving health. Health includes both the health of individuals as well as of groups of individuals or populations. The classification of health expenditures is based on: those entities who finance (sources), those who pay the entities providing the care (financing agents/intermediaries), and those entities providing the care (providers). National Health Expenditure (NHE)and Total Health Expenditure (THE): The National Health Expenditure (NHE) and THE are very distinct in NHA literature (Producers’ Guide) and they are important for international comparison. THE covers all spending on core activities (personal and collective health care activities) (HC.1.1 – HC.1.7) plus HCR1.2 Capital Formation, on the other hand NHE covers all spending made in both core and non‐core health (health related) activities. Reported expenditures Expenditures reported in this report refer to a financial year(s), which start 1st July and ends 30th June. Currency used in this report is Uganda shilling (UGX), other currencies were converted using the annual average exchange rate provided by the MOFPED1.See glossary; Annex 1 for definition of entities.

1In 2008/09, the annual average exchange rate was US$1 = UgShs 1930 and in 2009/10 was US$1= UgShs 2029; this rate was applied to convert the Uganda Shillings amount into US$, and vice versa. While for the Euro, respective exchange rates were 1Euro = UgShs 2,607.1 in 2008/09 and 1Euro = UgShs 2,742 in 2009/10

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1.2 Health Status in Uganda 1.2.1 Health outcomes: The health outcomes for the country over a period of 10 years are shown in Table 1. The current annual population growth rate stands at 3.2 and is among the highest in the world. The population is largely rural based although rapid increases in urbanization have been registered in the recent past. A slight improvement in life expectancy was registered between 2001 and 2002 but the current estimate of 50.4 years is still low. Table 1: Health outcomes and disease profile Indicator 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Population (million) 23.3 24.1 25.1 25.9 26.7 27.6 28.6 29.6 30.1 31.8

Urban (million) 2.8 2.9 3.1 3.2 3.4 3.5 3.8 4.3 4.5 4.7

Rural (million) 20.5 21.1 22.0 22.6 23.3 24.0 24.9 25.2 26.1 27.1

Life expectancy at birth (total) 48 50.4 50.4 50.4 50.4 50.4 50.4 50.4 50.4 50.4

Life expectancy at birth (male) years

46 48.8 48.8 48.8 48.8 48.8 48.8 48.8 48.8 48.8

Life expectancy at birth (female) years

51 52.8 52.8 52.8 52.8 52.8 52.8 52.8 52.8 52.8

Infant mortality rate per 1000 live births

97 87 87 87 87 76 76 76 76 54

Under five mortality rate per 1000 death

157 156 156 156 156 137 137 137 137 90

The leading causes of morbidity and mortality are shown in Table 2. Communicable diseases account for the biggest burden of disease although there is an increasing trend in incidence of Non communicable diseases as well.

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Table 2: Leading causes of mortality and morbidity Top 5 causes of mortality (%) (Hospital Based Mortality)

Malaria (14%)HIV/Aids (10%) Pneumonia (8%) Anaemia (8%) Tuberculosis (6%)

Top 5 diagnoses for hospital admissions (%)

Malaria (31%)Anaemia (7%) Pneumonia (6%) Respiratory infections 4% Injuries (4%)

Top 5 diagnoses for outpatient services (%)

Malaria,No pneumonia‐cough or Cold, Intestinal worms Skin Disease Diarrhoea‐ Acute

1.2.2 Purpose of NHA and its sub‐accounts NHA and its sub‐accounts are internationally accepted tools for collecting, cataloguing and estimating financial flows through the health system regardless of the origin or destination of funds. The NHA and its sub‐accounts provide evidence that can guide development of health financing strategy, resource allocation decisions, and health policy dialogue at several levels in the system, guide budgetary allocations to and within the health sector while providing a platform for comparisons with other country’s health expenditure profiles. The overall objective of this NHA study was to track the amounts and flows of financial resources into the health system in Uganda for financial year 2008/09 and 2009/10 and, respond to key health financing policy questions in the health sector. 1.2.3 Health Financing Policy Issues Resource Envelope

How much funding is available in the health sector? Who is paying? What are the modes of payment? How does Uganda’s spending per capita compare with its East African Community

peers?

Management of resources

• Who has programmatic control and make decisions relating to allocation of the resources?

• How much of health services expenditure is pooled?

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What services are purchased using the funds and what level of the health system?

• How much are we spending on curative vs preventive services? • What is the balance in spending between providers at different levels? Does

spending promote utilization of lower facilities for primary level care?

• What was the balance between administration and direct service delivery? Equity concerns

• What is the burden on households?

• What is the Out‐of‐Pocket expenditure by geographical area?

Staff accommodation: Kabale hospital Nurses hostel almost complete.

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1.3 NHA Entities in Uganda 1.3.1 Sources Building on previous NHA work undertaken in Uganda, the following sources have been identified as the key players in funding the health sector:

1. Government of Uganda (GOU)/Public ‐ Central and Local governments 2. Rest of the World (Donors, International NGOs, GHI) 3. Non‐Governmental Organizations (NGOs) 4. Households 5. Employers

Government are categorized as public funds, Donor funds categorised as rest of the world whereas the remaining sources of funds, including NGOs, Households and Private employers are referred to as private sources. The Government of Uganda: The principal ways in which GOU funds the health sector is through the health sector budget and local governments. In some instances however, government owned enterprises do provide funding for health care. Local governments in Uganda are legal entities and generate revenue from taxes. Part of this is used to fund health services. The GOU budget derives from two significant sources – tax revenues and loans. Government is an employer and provides some of its employees with health goods and services. Government employees can be broadly separated into those in the Civil Service, and those employed by autonomous government institutions often referred to as parastatals. For civil servants, the services may be provided in‐kind at public facilities (free or heavily subsidized) or in form of medical allowances for very senior officials. Employees of parastatals often receive in‐kind services at in‐house facilities or are insured by their employer or given a medical allowance. In the recent past, some line Ministries have paid insurance premiums for their employees. In this report, government and public as a source are used interchangeable Rest of the World (ROW):Donors or development partners contribute to the health sector through general budget support some of which is specifically earmarked for health, project support or global development initiatives. Donorsconsist of multi‐lateral donors such as the World Bank, the United Nations agencies and African Development Bank, bi‐lateral donors such as Belgium, Department for International Development (DFID), Ireland Aid, JICA, SIDA, USAID and Global Health Initiatives such as PEPFAR, GF and GAVI. With budget support, disentangling donor contribution to the health sector is difficult due to basket funding. That is, funds are provided to the pool without being earmarked.

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However the proportion of the total contributed by tax revenue and donor funding can still be worked out by considering the overall donor proportion of the macro GOU budget. This same proportion was applied to allocation within the health sector to get an insight into how much of the sector budget is donor funded. For the years under study, grants through budget support contributed 40%,2008/09 and 41%, 2009/10.[MOFPED Approved Budgets, FY2008/9 and FY2009/10)] Non‐Governmental Organizations (NGOs) or Private‐not‐for Profit (PNFP) institutions: PNFPs include local and international organizations and can be divided into facility based (FB PNFPs) and non‐facility based (NFB PNFPs). PNFPs/NGOs often contribute own resources towards health service costs, which they may have raised by fundraising locally or abroad, or from Income Generating Activities (IGAs), and therefore act as sources of health financing. Majority of the FB‐PNFP are religious‐based health care providers existing under four umbrella organizations: the Uganda Catholic Medical Bureau (UCMB), the Uganda Protestant Medical Bureau (UPMB), The Uganda Orthodox Medical Bureau and the Uganda Muslim Medical Bureau (UMMB). The Bureaus together represent 78% of the PNFP health units while the rest fall under other humanitarian organizations and Community‐based Health Care Organizations. Households: The recently published Uganda National Household Survey shows that an average Ugandan household spends a significant proportion of their annual expenditure on “health and medical care”. It is clear that the vast majority of this expenditure takes place in the private for profit sector, including private clinics, drug shops and traditional healers. Households also make financial contributions towards the costs of GoU and PNFP health services. Employers: Employers are often a neglected source of health care financing, as the various health benefits they provide to their workers may not be visible outside the organization. Employers may contribute towards the health care system using exactly the same financing mechanisms utilized by households, namely: User fees, some employers are prepared to pay, or subsidize the user fees incurred by their employees (or even their family members) in PNFPs or GoU private wings and payment is frequently in the form of a reimbursement. Employers also pay for health services by contributing to premiums held by Private Insurance Companies and, some of them do run on‐site health facilities. 1.3.2 Financing Intermediaries Financing Intermediaries (FIs) are entities, which receive funds from sources and make decisions about which health goods and services are to be procured and which institutions or agencies are to provide them. FIs are therefore responsible for mobilizing and allocating health resources. FIs are a very important link in the Health Financing Structure. FIs are public or private, and include:

8

Public Intermediaries: Ministry of Health Other line Ministries e.g.– Ministry of defence, Ministry of internal Affairs – Police;

Prisons; Ministry of education and Sports; all government bodies as employer; Local Government Health Services National Referral Hospitals Regional Referral Hospitals Other health institutions e.g. National Medical Stores Parastatal Employers

Private Intermediaries: Non‐Governmental Organizations or Private‐not‐for Profit Institutions Private Insurance Companies Community‐based Insurance schemes Private Employers Households (Out‐of‐pocket spending)

The different FIs receive funds from a different combination of the sources discussed before. The relationships are quite complex, yet important for understanding the relationship between policy and funding of the different components of health services. 1.3.3 Providers These are the institutions that convert funds into health services. They can also be classified as public and private providers, which include: Public Providers

Ministry of Health National Specialist Hospitals National level institutions – e.g. Blood Transfusion, Public Laboratories and National

Medical Stores Regional Referral Health Hospitals Local Governments Health Services – hospitals and Lower Level Units and other Ministry of Defence hospitals, clinics and other Ministry of Education and Sports – teaching hospital, training institutions, and

institution clinics Uganda Prisons Providers – hospital and clinics Uganda Police Providers – clinics

Private Providers

NGO hospitals and clinics NGO country programmes Pharmacies and drug shops Private health practitioners – hospitals and clinics Traditional Healers Private Employers providers – hospitals and clinics Private Health Practitioners:

9

Traditional and Complementary Medicine Practitioners: Of late, a number of non‐Ugandan Traditional Medicine Systems have been

introduced into the country. These include the Chinese and Ayurvedic practiced from China and India respectively. Other systems like Reiki, Chiropractice, Homeopathy and Reflexology are among later practices introduced into the country.

Staff apartments at Mbale Hospital

10

2. METHODOLOGY

2.1 Sampling and data collection methods 2.1.1 Introduction Health expenditure data was collected in line with the NHA methodology. Primary and secondary data sources were used to construct the required matrices and in the subsequent analysis of expenditures. In kind contributions (mainly drugs and equipment) were monetised as much as possible using drug price lists as provided by the National Medical Stores in the case of drugs, prices on delivery documents and advice from the infrastructure division of the MOH for equipment. The data for the NHA was compiled by the MOH team supported by development partners and technical assistance from a consultant. The Steering Committee was overseeing activities of the NHA team and monitored its progress. Only expenditure figures have been used in this study. 2.1.2 Government agencies/institutions Details of expenditure as reported in the final audited accounts of government agencies (ministries and institutions) were collected. Line ministries and Central level institutions: The MOH and all the 7 relevant line ministries are included in the survey. Related line ministries are selected on the basis of having health service provision institutions (Ministry of Internal affairs, Ministry of Defence) and carrying out functions central to MOH operations (Ministry of Education and Sports that oversees training of health workers), responsible for service delivery (Ministry of Local government), overseeing government business and coordinating multi‐sector efforts (Office of the prime minister), responsible for health related aspects of sanitation (Ministry of Water and Environment) and responsible for mobilizing communities for health (Ministry of Gender and Social Development). All responded and provided required data. All central level institutions were surveyed and these included;

• National level Hospitals (Mulago and Butabika)

• Health service commission

• Uganda AIDS commission

• Uganda blood transfusion services

• Uganda cancer institute

• Uganda Heart Institute

• Medical councils (2)

• National Medical stores

• Ministry of Health

11

Regional Referral Hospitals: There are 13 RRH and 11 were surveyed. Moroto and Mubende RRH have recently been created and would not have data as RRH for the years of the study. Response rate was 100%. Local governments: Currently there are 137 Local governments ‐112 Districts and 25 Municipalities. Since the survey covered the period 2008/09 and 2009/10, there were 80 districts by then and 13 municipalities. So the sample frame for Local Governments was 93 Local Governments. The sample surveyed was arrived following stratified random sampling taking into consideration regional representation and, random selection was done within each strata using probability proportionate to size. Kampala Capital City Authority (KCCA) was purposefully selected because it is the capital city endowed with a large population; many providers and numerous infrastructures (see Table 3). The general formula for sample size determination for stratified sampling design is given by;

( )

∑

∑

=

=

+⎟⎟⎠

⎞⎜⎜⎝

⎛=

H

hhh

H

h h

hh

SNZdN

nnSN

n

1

2

22

22

1

22

α

The type of allocation method within stratified sampling that was employed was proportional to stratum Size. The Sample size formula therefore per stratum is;

( ) hhhh nWNNnfNn === , Where NNW hh = is the stratum weight, N is Population (sampling frame), n is sample size, P is sample proportion.

It is important to note that the Sampling Fraction Nnf =

is constant across strata.

12

Table 3: Determining the sample size for local governments

Component Estimate Notes

Total population 92 Total Number of Districts/Municipalities

sample proportion( p)= 0.95 Proportion

z= 1.96 z‐value at 95% confidence

q= 0.05 q=1‐p

pq= 0.0475

B= 0.05 We require a level of precision with a standard

error no more than 0.05

B squared= 0.0025

deff= 1.1 1+(N‐1)s

Number of Stratum 5 Five strata: Central, Eastern, Northern,

Western and Municipalities

Unrestricted sample size 73.0

Implied sample size 40.9

To select a sample of 40 local governments (n=40) which were surveyed; the country was divided into four traditional regions, that is,central (16 districts), eastern (24 districts), northern (21 districts) and western (19 districts). Random selection was done within each strata using probability proportionate to size. A total of 40 districts were selected, but given more resources realized an additional 13 municipalities were selectedfrom the strata giving a total of 52, excludingKCCA which was purposefully selected (see Table 4). All the 53 Local Governments sampled responded.

Table 4: Details of selected local governmentsfrom each region

Local Governments N (n) Sample (n) Sample size

Central 15 7.741 7

Eastern 24 11.612 12

Northern 21 10.161 10

Western 19 9.193 9

Municipalities 13 13 13

KCCA 1 1 1

Total 93 39 52

General hospitals: There are 99 General hospitals (public and PNFP) which receive funding from the Central Government. The sample to be surveys was determined through stratification by ownership (public and PNFP) the simple random selection from each strata (see Table 5).

Table 5: Th

C

1 To

2 sa

3 z=

4 q

5 p

6 B

7 B

8 d

10 N

11 U

12 Im

14 A

13 A

15 A

A total 5PNFP owselected full sampAll 28 PN= 2.18. Parastataand a ful DevelopmInitiative100%. Tdisbursem

he sample for g

omponent

otal populatio

ample proport

=

=

q=

=

squared=

eff=

Number of Stra

Unrestricted sa

mplied sample

Adj. for design e

Adj. for propose

Adj. for non‐res

3 general howned and 16responded ple. (FiguresNFP Hospital

als: There wl sample wa

ment Partnes supportinhe list of doment report

general hospit

n

ion( p)=

tum

mple size

size

effect

ed number of s

sponse

ospitals wer6 were gove(38/16 =2.3s obtained ws sampled r

were 24 regiss arrived at

ers/Donors:g the healtnors active its for 2008/0

tals to be surv

E

stratum

re surveyed ernment ow75). Totals wwere compaesponded a

stered parasby multiplyi

: There wereh sector anin the health09 and 2009

13

eys is derived

Estimate N

99 To

0.98 Pr

1.96 z‐

0.02 q=

0.0196

0.05 Wst

0.0025

1.1 1+

2 TwPN

30.1

23.1

25.4

50.8

53.3

of these 44 wned.All the were multiprable to MOnd full samp

statals and wng by the w

e 21 develod were all h sector was/10.

as follows

otes

otal Number o

roportion

‐value at 95% c

=1‐p

We require a letandard error n

+(N‐1)s wo strata: GeNFP

responded.16 governm

plied by the OFPED budgple was built

were all sameight 24/14=

pment partnsurveyed ws obtained fr

f Hospitals

confidence

vel of precisiono more than 0

eneral Hospit

. Twenty eigment hospitaweight 2.37ets for thost using a we

mpled. Only 1= 1.714.

ners and 3 Gith a responrom MFPED

n with a 0.05

tals and

ght (28) werals that wer75 to arrive ase two yearseight of 61/2

14 responde

Global Healtnse rate of on the dono

re re at s). 28

ed

th a or

14

Bilateral Multilaterals Global health initiatives

• Belgium

• European Union

• DFID

• Italy

• USAID

• Sweden

• JAPAN

• GERMANY

• AUSTRIA

• NETHERLANDS

• IRELAND

• NORWAY

• CHINA

• DANIDA

• Norway

• Africa Development Bank

• CANADA

• UNFPA

• UNDP

• UNICEF

• WHO

• GAVI

• GLOBAL FUND

• PEPFAR

Facility based PNFP: These are organized under four Umbrella Organizations (Uganda Catholic Medical Bureau, Uganda Protestant Medical Bureau, Uganda Muslim Medical Bureau, UgandaOrthodox Medical Bureau). Data for the 28 selected hospitals was collected from the health facilities.Expenditure for PNFP lower level units were captured under the Local Governments PHC expenditure. The tool used for Local Government authorities provided for capture of information on Lower Level PNFP facilities. Data sources included:

• Data routinely available at hospital level.

• Data from the Public Private Partnership in Health (PPPH) unit, MOH

• GOU financial publications to get data on subsidies provided to these institutions2 Non‐Facility based PNFP (NGOs): The non‐facility based PNFPs are numerous in number and there is no comprehensive list. Two sampling methodologies for non‐facility based NGOs were employed. The first was NGOs funded by Health Development Partners who signed the compact. A list of NGOs – 41 in total ‐ benefiting from Health Development Partners funding were obtained from Health Development Partners expenditure reports and were all surveyed. Data for this category of NGOs was readily available and they were judged to be managing substantial amounts. The second category is that of registered Non‐Governmental Organizations. An inventory of NFB‐PNFP operating in the health sector was obtained from the NGO Board and the NGO

2 District Transfers for Health Services 1998/99, 1999/00 and 2000/01

15

forum. These were stratified according to country of origin into international or indigenous. NGOs whose country of origin was unlisted were excluded from the sample. International NFB‐PNFP: To determine the expenditure of health care we assumed that the NFB‐PNFP originating outside of Uganda are larger, able to mobilise and spend more on health than the indigenous NFB‐PNFP. There were 41 international NFB‐PNFPs under (DFID,USAID,UNICEF) and were all sampled. Indigenous NFB‐PNFP/NGOs:It was assumed that NGOs operating in more than one district had bigger operations and sizable expenditures compared to those operating in only one district. NGOs operating in only one district were thus excluded from the study.Other local or indigenous NGOs numbered (used health directory) totalled 156 out of which 83 were randomly selected and 53 responded. The full sample for this category of strata was arrived at using the weight 156/53= 2.943. 2.1.3 Private firms: A list of private firms in the country was obtained from the Census of Business Establishment conducted by the Uganda Bureau of Statistics. To determine the expenditure on health care by private firms, we assumed that:

Firms employing less than 100 employees spend minimal amounts of funds on health care

The level of expenditure is not the same for different sizes (in terms of establishment) of businesses

The expenditure level for different types of businesses (agricultural, industrial, services, manufacturing) is not similar

Large businesses (in terms of annual turnover) spend more than relatively smaller businesses

Business establishments employing less than 100 employees were excluded from the study. Remaining firms were 78 in total (N = 78). Two‐stage stratification was employed.

• In Stage I, the nature of business establishments was stratified by business establishment Service (utilities, insurance, transport, communication, finance, hotels and banking), Industrial (construction, manufacturing, mining,) and Agriculture.

• In stage 2; stratification was done by number of employees; above 1000, 500‐1000, 200‐500 and 100‐200.

Table 6: Th

Compon

Total po

sample z= q= pq=

B= B squardeff= NumberUnrestrImplied Adj. for Adj. number Using ranForty twwas arriv 2.1.4 PThere arOrganizaOrganizasurveyedall respo

2.2 EstimHealth eUganda Nto a perpocket exto obtainmultiplieestimatedeflator.

he sample of p

nent

opulation

proportion(

ed=

r of Stratumicted samplesample sizedesign effecfor pro

r of stratum

ndom samplo (42) out oved at by usi

rivate Healtre 3 ‐healthtions (AAR tions (AON)d given the fnded.

mation of Ho

xpenditure National Hoiod of 30 dxpenditure an the averaged by 12 ‐ ths from the The compo

private firms to

E

p)=

e size e ct posed

ing within eof 78firms wng the weig

th Insuranceh insurance and Intern) and 2 whicfact they are

ousehold out

estimates wousehold Surdays precediand divided ge amount. e number obase estim

osite consum

o be surveyed

Estimate

78

0.99 1.96 0.010.0099

0.05 0.0025 1.1 3

15.2 12.8 14.1

42.2

ach stratumwere selecteht 78/26=3.

e companiesational Air ch are provide few and th

t‐of‐pocket

were derivedrvey for the ing the survby the samp To obtain

of months inates of 200mer price ind

16

Total

z‐

We reqstand

m, a final samed. Twenty s

in UgandaRescue) ander based Ceir full oper

expenditure

d from a na year 2009/vey. We comple size – theannual esti a calendar 09/10, we udex (CPI) wa

Not

Number of P

Propo‐value at 95%

q=1

quire a level dard error no

1+(NThree

mple for the ssix (26) resp

a. There ared there areCASE clinic arations are a

e

ationally rep/10. The expmputed thee number ofmates, the year. In ordused the cons used to sc

tes

Private Emp

ortion % confidenc1‐p of precisiono more than N‐1)s strata:

survey was sponded and

e 2 Health e 3 Health nd KADIC. Aall on health

presentative penditure es total housef individuals monthly eser to obtainnsumer pricale the 2009

loyers

ce

n with a n 0.05

selected. a full samp

MaintenancManagemenAll these werservices, an

survey – thstimates refeehold out‐oin the survetimates wern the 2008/0ce index as 9/10 estimat

le

ce nt re nd

he er of‐ey re 09 a te

17

to 2008/093.Out of Pocket expenditures for the employed, where reimbursements by the employer were made, were discounted for OOP and included under expenditures by firms.

Multi‐purpose Vehicles

3Uganda Bureau of Statistics indicates the CPI for 2008/09 and 2009/10 respectively as 114.75 and 129.61 with base period 2005/06=100. Therefore making the base 2009/10, the CPI for 2008/09 becomes (114.75/129.61=0.885).

18

3. RESULTS: General Health Accounts 3.1 Total health expenditure Table 7 shows that total health expenditure (THE) increased substantially from financial year 2008/09 to financial year 2009/10 in absolute and per capita terms. Absolute amounts increased from UGX 2.81 trillion ($1,455 Million) to UGX 3.23 trillion ($1,594 Million) while THE per capita increased from UGX 94,916 ($49) to UGX 105,506 ($52). This shows a desirable upward trend in total health spending per capita, implying more resources are becoming available to the sector. Table 7: Summary statistics: NHA General Health Expenditure

Indicators 2008/09 2009/10 Total population (Census results) 29,592,600 30,661,300

Exchange rate ‐ UGX PER $, (UBOS) 1,930 2,029 Total GDP at current prices (UGX Billions) 30,101 34,908 Total GDP at current prices (US$ Billions) 15.596 17.204 Total government expenditure (UGX Billions) 4,949 6,318 Total government expenditure (US$ Billions) 2.564 3.113 Total Health Expenditure (THE) (UGX Billions) 2,808.798 3,234.946 Total Health Expenditure (THE) (US$ Billions) 1.45 1.59 THE per capita (UGX) 94,916 105,506 THE per capita ($) 49 52 THE as a % of nominal GDP 9% 9% Total Government Expenditure on health (UGX Billions) 711.0185

696.2871

Total Public Health Expenditure per capita ($) 12.4 11.2

Government Health Expenditure as % of THE 25% 22% Govt. health expenditure as a % of total govt. Expenditure

9% 7%

Household expenditure on Health (UGX Billions) 1,214 1,372 Household expenditure on health as a % of THE 43% 42% Household Out of pocket spending on health per capita (UGX)

41,024 44,746

Household Out of pocket spending on health per capita($)

21 22

Financing sources as % OF THE

Public 16% 15% Private 50% 49% Donors and NGOs 34% 36% Financing agent distribution as a % of THE:

Public 25% 22% Households 43% 42% NGOs 30% 35% Private others 2% 1%

19

Indicators 2008/09 2009/10 Provider distribution as a % of THE:

Public 27% 23% Private 47% 48% NGOs 26% 28% Expenditure by providers as % of THE: National Referral Hospitals 3.08% 1.58% Regional Referral Hospitals 3.02% 2.46% General Hospitals 2.77% 3.32% PNFP Hospitals 8.17% 9.39% PFP Hospitals 9.15% 9.14% Government lower level units 7.63% 7.34% PNFP lower levels of care 3.73% 4.38% Private for profit Clinic and Drug shops 23.81% 22.98% All other OPD community and other integrated care centres

3.20% 0.23%

Traditional healers 0.38% 0.17% Provision and administration of public health programmes

24.84% 13.35%

Blood services 0.27% 0.57% Central MoH HQ 0.91% 6.94% District health office 0.31% 0.35% On‐site facilities to providers 0.27% 0.24% Research Institutions 7.95% 1.53% Training Institutions 0.08% 0.13% Institutions providing health related services 0.08% 14.99% Health providers nsk 0.16% 0.02% Expenditure by function as a % of THE: Services of Curative Care 54.89% 48.0% Services of Rehabilitative Care 0.03% 0.1% Ancilliary Services to Health Care 0.9% 2.2% Medical Goods Dispensed to Outpatients 8.2% 5.4% Prevention and Public Health Services (outreach) 22.8% 23.9% Health Administration and Health Insurance 5.7% 13.3% Capital formation for health care provider institutions

4.1% 2.9%

HCR expenditure 2.2% 7.1%

Uganda’s per capita spending compares favourably to that of similar countries. For example, it is estimated that Kenya spends about US$ 36 while Tanzania spends US$27 (see Table 8). This is still below the internationally accepted levels set by WHO as an expenditure of US$ 60 per capita on key health services and health related system costs, in order to make progress towards universal health coverage (WHO Report 2010). With regards to the Abuja commitment, Uganda ranks lowest. The health sector is still underfunded and there is a

20

stronger need for making available additional resources from other alternative financing mechanism to improve the health status of the Ugandan population. We are aware that it takes more than health financing alone to impact on mortality indicators, however, we note that there are some countries spending less than what Uganda spends but have better health outcomes for example Tanzania and Kenya. This points to more detailed analysis required to assess efficiency in expenditures. Table 8: Regional Comparison – Total Expenditure on Health Sources: World Health Statistics 2012; Mortality indicators for Uganda are from DHS 2011

3.2 Financing sources: Who pays for Health Care?

The health sector in Uganda obtains varying levels of funding from public sources (central government, local governments and parastatals, private sources (households, firms and local NGO’s) and external sources (donors, international NGOs and GHI).The details are provided in Annex . Table provides a breakdown of THE by financing source. Public Funds accounted for 16% of THE in financial year 2008/09 but decreased its relative contribution to 15% in financial year 2009/10. Private funds contributed 50% and 49% of the resources to the health sector in financial year 2008/09 and financial year 2009/10 respectively. The rest of the world (international NGO’s and Donors) contributed 34% in FY2008/09 and 36% in financial year 2009/10.

Countries

Total Expenditure on Health as % of GDP (2009)

Total Expenditure on Health per capita (USD)

(2009)

Government expenditure on health as a % of TGE (2009)

Under 5 Mortality rare (2010)

Maternal mortality rate (2010)

Tanzania 5.5 27 12.9 76 460Zambia 6.2 63 15.7 111 440 Malawi 6.7 25 14.2 92 460 Mozambique 5.4 23 12.2 135 490 Kenya 4.8 36 7.3 85 360 Rwanda 10.1 52 20.1 64 340Uganda 9.0 52 7.0 90 (2011) 435 (2011) Ghana 5.0 54 12.4 74 350

21

Table 9: Financing sources – General health 2008/09 and 2009/10

FY2008/09 FY 2009/10

Amount in Billions

UGX Percentage Amount in Billions

UGX Percentage Public Funds 449.98 16% 472.35 15% Private Funds 1,392.08 50% 1,571.66 49%ROW Funds 966.42 34% 1,190.68 36% TOTAL 2,808.49 3,234.68

3.3 Total general government health expenditure (TGGHE)

Total general health expenditure (TGHE) as a % of total government expenditure (TGE) was 9% and 7% in 2008/09 and 2009/10 respectively which still falls below the Abuja Target set is 15%. The fourth round of NHA revealed that there has been an increase of TGGHE from UGX450 Billion (US$ 233.12million) in financial year 2008/09 to UGX473 Billion (US$ 223.12million) in financial year 2009/10. We note that prioritization of health in percentage terms is likely to remain low because of the renewed emphasis on infrastructure in the National Development plan (see Table 10). Table 10: Percent sector allocation of Government of Uganda funds, excluding donors

2008/09(% of TGE)

2009/10(% of TGE)

Accountability 6.4 6.4 Agriculture 3.5 3.9 Education 17.4 17.4 Health 8.3 8.1 Interest payments 8.4 6.9 Justice/law and order 5.9 6.4 Parliament 2.5 2.3 Public sector management 8.7 8.9 Public administration 3.0 4.1 Roads 16.3 16.0 Security 10.5 9.1 Social development 0.5 0.5 Tourism, trade and industry 0.6 0.8 Water 2.2 2.3 Energy and mineral development 5.6 6.6 Lands housing and urban development 0.3 0.4 Note: Own computation based on approved budget estimates for the respective financial years

22

3.4 Private sources of financing Table 11: Private sources of funds

FY2008/09 FY 2009/10

Amount inBillions UGX Percentage

Amount in Billions UGX Percentage

Households 1,214.06 87% 1,371.81 88% NGO’s 95.45 7% 100.86 6% Private firms 52.42 4% 63.23 4% Other Private Funds 30.15 2% 35.76 2% TOTAL 1,392.08 1,571.66 As shown in Table 11, much of the private health financing is contributed by households. Their contributions increased from UGX1.2 trillion in financial year 2008/09 to 1.37 trillion in financial year 2009/10. Households contributed 87%,2008/9 and 88%,2009/10 of total private funds. Such level of OOP spending suggests that financing of health care is less equitable, with high likelihood of financial catastrophe on households. Where OOP expenditure on Health exceeds 20% of THE, the risk of financial catastrophe from OOP expenditure increases significantly (WHO Report 2010). Private firms are a minor player contributing only 6% of THE.

3.5 Rest of the world The bulk of funding from external sources is from bilateral, multilateral donors and GHI as shown in Table 12. Table 12: Rest of the World sources of funds

FY2008/09 FY 2009/10



Donors/HDPs and GHI 658.65 68% 851.67 72%International NGOs 308.08 32% 339.01 28% TOTAL 966.73 1,190.68

23

3.6 Comparison with Previous rounds of NHA

Table 13 shows THE for 4 rounds of NHA undertaken in Uganda. We note a gradual increase in the level of health expenditure over the period. Table 13: Comparison of First, Second, Third and Fourth rounds of NHA Health spending in Uganda ‐ UGX Billions

Entity 1998/99 1999/00 2000/01 2006/07 2008/09 2009/10

Public Funds 94 (17%) 104

(16.7%) 136

(18.2%) 235(15%)

450 (16%) 472 (15%)

Households 255 (46%)

279 (45%) 302

(40.5%) 826(51%)

1,214 (43%) 1,372 (42%)

NGO’s 45 (8%) 60 (10%) 101

(13.6%) 103 (6%) 126 (4%) 137 (4%)

Private firms 3 (1%) 2 (0.3%) 2 (0.3%) 52 (2%) 63 (2%)

ROW Funds 151 (28%)

176 (28%) 204

(27.4%) 445(28%)

966 (34%) 1,191 (37%)

TOTAL 548 621 745 1609 2808 32345Approximately 1% of NGO funds came from philanthropists.4

3.7 Financing Agents:(Who manages Health Funds?)

Table 14 and figure 1 show that the Non Public sector controls the biggest percentage of health expenditures. Comprehensive details are provided in Annex and Annex 4 Table 14: Expenditure by financing agents ‐ 2008/9 ‐ 2009/10

FY 2008/9 FY 2009/10

Amount in

Billions(UGX) % of Total Amount in

Billions(UGX) % of Total Public Sector 711.09 25% 696.29 22% Non‐Public Sector 2,097.71 75% 2,538.66 78%TOTAL 2,808.80 3,234.95

4Private firms were not included in the NHA study for FY2006/07.

Figure 1: P

Further alargest pboth yeaentities mthe expe Table 15: D

Public

C

Private

Detailed trunder stud

‐

500.0

1,000.0

1,500.0

2,000.0

2,500.0

3,000.0

Percentage exp

analysis of thproportion oars of study, manage abonditure in th

Details of trans

Central level District he

Ot

ransfers throudy, households

711

‐

00

00

00

00

00

00

FY

penditures thro

he Non Pubof total healfollowed by

out 3% (privahe Non Publ

sfers through t

institutionsealth service

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ther private

ugh all financins were the bigg

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ough the diffe

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ng agents are gest players fol

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24

erent Financing

Table 15 ing in the Non30% on averce and comm

financing agen

Y2008/09 25% 17%9% 75% 43% 30%2%

shown inFigullowed by NGO

696.2

FY 2

on‐Public Secto

g agents

dicates thatn Public Secrage for bothmunity base

nts

ure 2andFigureO’s.

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or

t Householdsctor, 43% onh years and ed insurance

FY200221487842351

e 3. For both

8.66 (78%)

ns UGX)

s manage thn average foother private schemes) o

09/10 2% 4% % 8% 2% 5% %

h financial yea

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ars

25

Figure 2: Detailed breakdown of expenditures through financing agents – FY 2008/9

‐Ministry of Health, 7.71%

‐Ministry of Defence, 0.16%

‐Ministry of Education, 0.05% ‐ Uganda Prisons

Services, 0.04%‐ Uganda Police Services, 0.06%

‐ National Referral Hospitals, 2.22%

‐ Regional referral

hospitals, 1.73%

‐ Other ministries, 0.28%

‐ other National level Institutions, 4.34%

‐ District Health Services, 8.73%

‐ Private Health Insurance, 1.04%

‐ Households, 43.14%

‐ Not for profit/NGO'S, 30.00%

‐ Private Firms, 0.50%

26

Figure 3: Detailed breakdown of expenditures through financing agents – FY 2009/10

3.8 Health providers: (Who uses Health Funds to deliver Health Care?)

Table 16indicates that Hospitals accounted for 31% and 27% of THE over the study period. The Lower level health facilities accounted for 34% and 35% of THE in financial years 2008/09 and 2009/10 respectively. The details are provided in ‐ Annex 5 and Annex 6 . Table 16: Expenditure by level of care 2008/09 ‐ 2009/10

FY2008/09 Billions (UGX) % of Total

FY2009/10 Billions (UGX)

% of Total

Hospital Level 884.62 31% 866.45 27%Lower Level 941.07 34% 1129.93 35%Other Health Providers 983.12 35% 1238.56 38%

TOTAL 2808.80 3234.94 Other health providers include traditional healers, public health programmes, central management Institutions and research and training institutions.

Ministry of Local Government, 4.06% ‐Ministry of

Health, 1.97%


‐Ministry of Education, 0.05%

‐ Uganda Prisons Services, 0.04%

‐ Uganda Police Services, 0.07%

‐ National Referral Hospitals, 1.59%

‐ Regional referral hospitals, 1.56%



‐ District Health Services, 7.64% ‐ Private Health

Insurance, 1.20%




27

3.9 Health functions: (What services and products are purchased with Health Care Funds?)

Curative services accounted for the highest percentage of health expenditure for both years. Although the biggest burden of disease is preventable, prevention services only accounted for 23% and 24% of THE in 2008/09 and 2009/10 FYs respectively.Table 17 and Figure 4 show the percentage expenditure by type of services provided (functions). Table 17: Expenditure against the different functions ‐ 2008/09 AND 2009/10

FY2008/09 FY2009/10

AmountBillions (UGX) % of Total

Amount Billions (UGX) % of Total

Curative functions 1,805.99 64% 1,802.35 56%Preventive functions 639.83 23% 774.77 24%Other Functions 362.98 13% 657.83 20%TOTAL 2,808.80 3,234.95Other functions include health care related functions, addendum functions and health functions expenditures not specified by kind.e.g Ancillary services

Figure 4: Percentage expenditure against the different functions ‐ 2008/09 and 2009/10

3.10 Household OOP expenditure on health

The annual total household expenditure on health was estimated at Ushs1,214.06 billion in 2008/09 and 1,371.81 billion in 2009/10. OOP Per capita expenditure on health is shown in Table 18.Table 18 details the average out‐of‐pocket expenditure on health per capita for the period under study. Household OOP expenditures have shown an increase over the years despite the government’s 2001 effort to provide financial protection and increase utilization by eliminating cost sharing within government facilities (Okwero et al). This can be attributed to a shift from using government facilities where quality of services offered remains low to using more of private sector services for the better‐off quintiles, and increased expenditure on commodities, supplies and private clinics for the poor due to stock‐outs in government health facilities (Nabyonga Orem et al. 2011).

1,805.99 (64%) 1,802.35 (56%)

639.83 (23%) 774.77 (24%)

0200400600800

1,0001,2001,4001,6001,8002,000

FY2008/9(Billions UGX) FY2009/10(Billions UGX)

Curative functions Preventive functions

Table 18: O

Year

A 2008/092009/10 Looking athings. pattern. and 2009Figure 5: A

FY200

FY2009

OOP per cap

Popuesti

9 29,590 30,66

at average eFirstly, the Secondly, a9/10. Average house

08/9(Billions U

9/10(Billions U

pita expendit

ulation mate

B 92,600 61,300

expenditure richest quinall income g

hold expendit

0

UGX)

UGX)

Richest

ture on heal

Out‐of‐pestimate (

C1,214.1,371.

by quintilesntile spent mroups regist

ture by quintile

64.65

73.05

138

1

100

Fourth t

28

th

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.06

.81

s in absolutemore than oered increas

es

8.54

156.54

198.12

223.87

200 30

third seco

Per capexpenditu

D=C/41,0244,74

e amounts –other quintilses in expen

7

320.27

361.8

00 400

nd Poores

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/B 26 41

in Figure 5,le which is nditure betw

89

495

0 500

st

Per capitexpenditure

21.2622.05

we note twthe expecteween 2008/0

5.3

559.67

600

ta e US$

wo ed 09

Figure 6providersfollowedaddition private cprofits es Figure 6: T

FY2008

FY2009/

shows thas between 2 by public fto stock‐ou

clinics and dspecially in u

Total househol

8/9(Billions UG

/10(Billions UG

Others

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d expenditure

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ased in exp2009/10. T

rivate‐not‐fow quality of also contribu

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aff housing

154.3

174.3

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29

enditure byhe highest uor‐profit andservices witutedto the h

ovider

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ospital

9.7

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Figure 7salmost aexpenditon medicearlier rexpenditand medhouseho Figure 7: T

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shows houseall expenditture comparcines than hresearch woture on hospdicines withlds to purch

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old health exure 8). Centrin health exalth expendindex while findings linker expenditu

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There was adicines had. Household009/10, whic2005/06) thconstant laclower leveler drug outle

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76

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an increase d the higheds spent morch differ frohat indicateck of supplies force moets.

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Figure 8: A

0

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200

300

400

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32

4. Conclusions and recommendations

4.1 Overall Health Spending • Households contribute over 40% of THE funds, which widens inequities in general

health, access and utilization of health care services. This also increases the incidence of catastrophic expenditures thus increasing incidence of poverty (Maximum recommended OOP level as a % of THE is 15%)

• Per capita government health on health was around 11US$, which is far below the estimated US$44 target of the innovative task force on health financing and estimated requirement in the HSSIP of US$41.

• Overall spending per capita is below the recommended level (US$49) compared to WHO recommended minimum level of US$60 to provide a MHCP (Trends 2005/6,US$32, 2000/01 US$19).

• Abuja Declaration on TGHE as % of TGE was a minimum of 15%, results showed Uganda at an average of 8% for the two years of the study.

• The non‐public sector is a major player managing over 75% of health expenditures.

• Biased expenditure on curative services accounting for 55% of THE for the two years of the study.

4.2 Recommendations

• Increase public spending to meet both the Innovative task force on health financing estimated requirement of US$44per capita and the Abuja Declaration target (15% of total government expenditure on health)

• Develop financing mechanisms to manage HH funds used as OOP payments in a more equitable way through pre‐payment mechanisms(e.g. National health insurance, community insurance schemes)

• Address the decline in the share of the provision of prevention and public health programs by increasing focus on preventive health care.

• Implementation of the PPPH policy that has just been finalised should be expedited and effective monitoring mechanisms, to monitor activities of non‐public providers should be put in place. In addition, harmonised and all‐encompassing planning frameworks must be implemented.

Reproductive Health Sub‐Accounts

34

5. Reproductive Health Sub‐accounts

5.1 Introduction The status of Reproductive Health (RH) in Uganda has been improving over the last ten years but at a relatively slow rate compared other East African Countries. The fertility rate is at 3.2% with significant variations by socio economic status (UBOS Statistical Abstract 2012). A low interest in family planning is still a huge challenge, although awareness of family planning techniques has increased in the recent years. Un‐met need for family planning remains high. Maternal mortality has been estimated at 435/100,000 births. In the years under review about 57% of the pregnant women were delivered by a professional medical worker but a much smaller percentage received post natal care. This is still below the MDG 5 target of 60% of births to be delivered by skilled provider. (UDHS, 2005/6) RH sub‐account captures and organizes expenditure information in two‐dimensional tables from financing sources to end users. The tables are the end result of the RH sub‐account as it aims to be comprehensive in scope, capturing public, private, and donor fund flows.

5.2 Policy‐related use of the Reproductive Health sub‐account While there may be more specific goals in a particular country context, generally speaking the RH sub‐account methodology aims to:

• Provide key expenditure information to guide the strategic planning of national policymakers, donors, and other stakeholders in the area of RH.

• Identify all sources, financial flows and uses of funds for RH in the context of overall health spending; and provide internationally comparable data. The RH sub‐accounts framework is internationally agreed and allows the preparation of RH estimates that are consistent and comparable.

• Inform the policy process and as such, the primary audiences such as RH programme managers, national policymakers, donors, and other stakeholders who use expenditure data for strategic planning in the area of RH care.

More broadly, the audience is those individuals, institutions, or groups that have an interest in the functioning and monitoring of the health system – in particular its RH programmes . These stake holders may require information on the financial structure of RH programmes such as;

What is the reliance on donors for RH services and commodities? What share of donor health funds are targeted for RH? While developing country governments have expressed great willingness to address RH issues, it is becoming apparent, particularly in

35

sub‐Saharan Africa that a large proportion of the resources used are provided by donors. Hence, there is a need to understand the role of donor funding and related sustainability issues; if donor funding for RH were dramatically reduced or withdrawn, would the government be able to mobilize funds to meet RH needs?

What proportion of public health funds is spent on RH care? This highlightsthe relative importance of RH on the government’s health agenda.

What is the financial burden of RH funding on households? How does this compare with

utilization rates of services and contraceptives? Households may also serve as a major financer of RH care, particularly through out‐of‐pocket spending (OOPs) on inpatient and outpatient services. Policy‐makers may be interested in understanding the burden of such financing on households and how this may be affecting the use or non‐use of RH services.

What types of services are financed by RH funds? This information reveals the amount

of resources actually spent on various Reproductive Health activities, such as family planning, maternal health, and information, education, and communication (IEC) campaigns. By comparing these results with official government policies, it is possible to see whether policies are actually being financed and implemented. Furthermore, specific financial data broken down by RH activities can inform the process of setting priorities for resource allocation across various interventions.

Who benefits from RH spending? In order to monitor progress towards financial equity

goals, it is necessary to understand the profile of the beneficiary population. For example, are the rich the main users of services? If so, could financial constraints be a barrier to use of services by the poor? Understanding spending by different socioeconomic groups is crucial in RH service delivery and financing. Such detailed equity analyses may require a greater effort and investment in completing the NHA, as they rely on good household survey data.

Who provides what RH services and where? In many countries, there has been a

proliferation of RH providers that has not been adequately coordinated or regulated by the government. RH Subaccounts can provide data on different types of providers, categorized by ownership (public/private).

How does financing of RH services compare with that in other countries? In the light of

international agreements on RH goals, there is strong interest from both national and donor governments in tracking resources for RH care across countries.

36

What are the implications of different health‐financing policy options on the mobilization and allocation of resources for RH? Equally, routine resource monitoring can reveal the drivers of expenditure. For example, an increase in the number of births may be related to increased investment in fertility interventions for women over 35 years of age. Or an increase in spending related to cancers of the reproductive system, such as the human papilloma virus (HPV) vaccine may reflect the introduction of new technology.

Are expenditures in line with national plans for investment in Reproductive Health? For

planning purposes, RH subaccounts can also inform estimations of gaps in RH financial resources.

The utility of the RH sub‐account depends on the extent to which it can address the questions in the minds of national health planners, policy‐makers, and donors. Although they have only recently been implemented, RH sub‐accounts have already begun to have an impact on policy. At the Special Session of the African Union Conference of Ministers of Health (Maputo, September 2006), the Ministers of Health adopted the sub‐accounts as a policy tool to advocate for increased resources. Specifically, the Ministers endorsed the following text; “It was recommended that health ministries’ use NHAs and [sexual and reproductive health] SRH sub‐accounts as tools in their policy dialogues” (African Union, 2006).

This subaccount sought to answer the following key policy questions: 1. How much is spent on RH care? 2. Who is paying, and what amount is paid towards RH services? 3. What services are being purchases? (expenditure by functional category) 4. How much are we spending per woman? (RH expenditure per woman or man of

reproductive age) 5. What is the relative importance of RH expenditure in the overall health expenditure (RH

expenditure as % of THE)

The following are key RH Sub‐accounts results: • RH expenditure as a percentage of THE was 16% in 2008/09 and 14% in 2009/10,

whereas women with the reproductive age bracket account for about 23% of the total population.

• Household expenditure on RH as a % of THE on RH was 67% in 2008/09 and 74% in 2009/10

• Government RH expenditure as a % of TGHE was 8% in 2008/9 and reduced to 7% in 2009/10.

• Household RH expenditure as a % of total HH health expenditure was 24% for both years.

• Health expenditure per woman of reproductive age was 34.0US $ in 2008/09 and 32.5US$ in 2009/10.

37

5.3 RESULTS: Reproductive Health Sub‐Accounts Table 19: Summary Statistics for Reproductive Health Sub‐account Expenditures Indicators 2008/2009 2009/10

Exchange rate ‐ UGX PER $, (UBOS) 1,930 2,029

Total Health Expenditure (THE) (Billions UGX) 2,808.798 3,234.946

THE (Billions $) 1.455 1.594

Total RH expenditure ( THErh)(Billions UGX) 446.513 465.460

Total population (Women of Reproductive age) 6,806,298 7,052,099

THErh as a % of general THE 16% 14%

THErh as a % of GDP 1.5% 1.3%

THErh per woman of Reproductive age UGX 65,603 66,003

THErh per woman of Reproductive age($) 34.0 32.5

Total Government Expenditure on health(Billions UGX)

450.290 472.610

Total Government expenditure on RH (Billions UGX) 35.798 33.221

Total Government expenditure on RH (Billions $) 0.019 0.016

THErh Government per woman(UGX) 5,260 4,712

THErh Government per woman ($) 2.7 2.3

Total government spending on RH as % of total Government expenditure on health

8% 7%

Total Non‐Public spending on RH (Billions UGX) 410.714 432.238

THErh Non‐Public per woman (UGX) 60,343 6,1292

THErh Non‐Public per woman ($) 31 30

Household expenditure on Health (THEhh) 1,214 1,372

Household expenditure on RH (Billions UGX) 294.0 335.7

Household expenditure on RH (Billions $) 0.15 0.17

Household expenditure on RH as a % of THE(UGX) 11% 10%

Household expenditure on RH as a % of THErh 67% 74%

Household expenditure on Rh as % of THEhh 24% 24%

FINANCING SOURCES AS A % OF THErh

Public 3.0% 3.8%

Households 66.8% 73.8%

Private others 6.6% 4.6%

ROW 23.6% 17.8%

FINANCING AGENT DISTRIBUTION AS A % OF THErh:

Public 8% 7%

Households 67% 74%

38

NGOs 21% 17%

Private others 4% 2%

PROVIDER DISTRIBUTION AS A % OF THErh:

Public 14% 11%

PFP (FB) 45% 47%

PNFP (FB) 21% 31%

NGOs and ROW (NFB) 17% 9%

FUNCTION DISTRIBUTION AS A % OF THErh:

Inpatient curative care (RH services) 52% 55%

Outpatient Curative Care( RH services) 33% 35%

Pharmaceuticals and other non‐medical durables for RH 6% 5%

Prevention and Public Health services(RH) 2.1% 2.3%

Capital formation for RH 1.9% 0.2%

Policy advocacy for reproductive health 0.1% 0.1%

5.3.1 Financing sources: Who pays for Reproductive Health Care? Table 20 indicates that private funds make up the largest percentage of THErh. Private funds accounted for 73.4%, 2008/9 and 78.4%, 2009/10 of RH services with households contributing most of the private funds.The public sector in Uganda contributed 3% and 3.8% of the reproductive health funds in financial year 2008/09 and 2009/10 respectively. Rest of the World (ROW) contributed 23.4% of the reproductive health funds in financial year 2008/09 and their contribution reduced to 17.8% in financial year 2009/10. Table 20: Financing sources – RH FYs 2008/09 – 2009/10

FY2008/09 FY 2009/10

Amount Billions UGX % of Total


Public Funds 13.31 3.0% 17.65 3.8% Private Funds 327.89 73.4% 365.05 78.4% ROW Funds 105.27 23.6% 82.75 17.8%

TOTAL 446.48 100% 465.44 100%

5.3.2 FiTable 21 in the coof study 2009/10 Table 21: F

Public SeNon‐PubTOTAL Figure 9: F

0

100

200

300

400

500

inancing Ageand figure 9untry. The Nwhile the prespectively

Financing agen

FY 2

ector lic Sector

inancing agen

35.80

FY200

ents: (Who 9 show that Non‐Public Sublic sector y.

nts for RH expe

2008/9 Am

Billio34144

ts for RH expe

(8%)

410.71

08/9(Billions U

Public

manages Rethe non‐pu

Sector contromanaged o

enditures FYs 2

mountns(UGX) 5.8010.7146.51

enditures FYs 2

(92%)

UGX)

Sector N

39

eproductive blic sector molled over 90only 8% and

2008/09 – 200

% of Tota

8%92%

2008/09 – 2009

33.22

FY200

Non‐Public Sec

Health Fundmanages the0% of RH res7% of these

09/10

al Am

Billio34346

9/10

(7%)

432.2

09/10(Billions

ctor

ds?) e biggest sumsources for te funds in FY

FY 2009/mount ons(UGX) 3.2232.2465.46

24 (93%)

s UGX)

m of RH fundthe two yeaY2008/09 an

/10

% of Tota

7%93%

ds rs nd

al

40

Table 22 shows that households managed about 70% of the reproductive health funds in the two years, followed by NGO’s in order of significance. The public sector is only a minor player. Details of transfers through the different FA are shown in Figure 10 and Figure 11 .Table 22: Transfers through financing agents FY 2008/9 FY 2009/10Public 8% 7%

Central Level Institutions 7% 6% District Health services 1% 1%

Private 92% 93% Households 67% 74%

NGOs 21% 17% Other Private 4% 2%

Other private includes private health insurance and private practitioners

Launching of the Public Private Partnership for Health Policy

41

Figure 10: Management of funds spent on RH – FY 2008/9

Central Government, 0

‐Ministry of Health, 2.95%


‐Ministry of Education, 0.00%

‐ Uganda Prisons Services, 0.03%

‐ Uganda Police Services, 0.01%

National Referral Hospitals, 0.74%

‐ Regional referral hospitals, 1.09%



‐ District Health Services, 0.86%

Private sector, 0.00%




‐Private providers, 0.00%


42

Figure 11: Management of funds spent on RH – FY 2009/10

Ministry of Health, 2.96%

Ministry of Defence, 0.07%

Ministry of Education, 0.00%

Ministry of Internal Affairs‐Uganda Prisons

Services, 0.03%Ministry of Internal Affairs‐Uganda Police

Services, 0.05%


Regional referral hospitals, 1.63%

Other ministries, 0.01%

other National level Institutions, 1.10%

District Health Services, 1.05%






43

5.4 Reproductive Health expenditure by providers: Utilization of RH services increased the most among lower level units (4% increment) than among hospital level units (1% increment) in the two years of study. Utilization of RH services by other providers such as clinics and traditional birth attendants among others fell by 5% within the study period. Table 23 shows the providers of reproductive health services in the country and how much of the THErh is spent by each level of provider. Table 23: Expenditure by level of care FY2008/09 ‐ 2009/10 FY2008/09 FY2009/10 Amount in

Billions(UGX) % of Total Amount in

Billions(UGX) % of Total

Hospital Level 172.81 39% 187.05 40%Lower Level 169.52 38% 193.41 42%Other Health Providers 104.18 23% 85.00 18%TOTAL 446.51 465.46

5.5 Reproductive Health expenditure by functions: (What RH services are purchased with RH Funds?)

Table 24 indicates that on average for the two years 93.5% of the Reproductive Health expenditure was spent on curative services, about 2.5% on preventive services and 4% on other Reproductive Health services. Table 24: Reproductive Health expenditure by function FY2008/9 ‐ 2009/10

FY 2008/09 FY 2009/2010 Amount in

Billions(UGX) % of TotalAmount in

Billions(UGX) % of Total

Curative Functions 413.77 93% 439.41 94%Preventive Functions 9.43 2% 13.52 3%Other functions 23.31 5% 12.53 3%TOTAL 446.51 465.46

Other functions include health care related functions, addendum functions and health functions expenditures not specified by kind.

44

5.6 Conclusions • Sustainability of RH services is a challenge given the low government investment at

less than 4% of THErh in both years • Ensuring RH policy implementation and overall monitoring and evaluation of RH

services remains problematic for the government, with the non‐public sector managing over 90% of funds for THErh

• Investment in RH prevention services is very low at only less than 4% of THErh for both years of the study

• Households are shouldering a heavy burden of financing RH service contributing over 65% of THErh

5.7 Recommendations • Devise a mechanism to distribute RH commodities for free through the private

sector so as to reduce the burden of financing on HH who prefer to obtain commodities outside of public facilities

• Increase government allocation of funds to maternal and newborn health care for sustainability, and as an expression of government’s commitment.

• Promote effective public‐private partnerships in order to strengthen the coordination and management of RH services.

Masaka RRH Inside Operation Theatre

45

Child Health Sub‐Accounts

6. Chil

6.1 Intro Uganda hwas dueimmunizpartners.even high Figure 12:

Source: Ug The ratiowithin nadie each under‐fivconventireport onintervent CH Sub a

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27

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remendous vements in age, targeteess, child mareas.

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46

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11

lt in the desents. For insWorld. The Mar 2015. In ach commits interventioecisions on t

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47

7. To what extent are child health expenditures dependent on private sources and ROW?

The following are key CH Sub‐accounts results:

• CH expenditure as a % of THE was 14% in 2008/09 and 2009/10 (THECH was Shs.389bn yet required was 1.25trillion (Child Survival Strategy). Whereas children under 5 years account for about 20% of the population.

• Household expenditure on CH as a % of THE on CH was 63% in 2008/09 and 61% in 2009/10

• Government CH expenditure as a % of TGHE was 11% for the two years of study • Household CH expenditure as a % of total HH health expenditure was 20% for both

years. • Health expenditure per child below 5 years was 40 US $ in 2008/09 and 39US$ in

2009/10.

6.2 Results: Child Health Sub‐Accounts Table 25: Summary Statistics for Child Healthsub‐account expenditures Indicators 2008/2009 2009/10 Total population of children under‐five 5,018,151 5,670,228 Total Health Expenditure (THE) (Billions UGX) 2,808.798 3,234.946 THE (Billions $) 1.45 1.59 Total CH expenditure ( THECH)(Billions UGX) 389.031 449.189 THECH (Billions $) 0.20 0.22 CH Expenditure as a % of THE 14% 14% THECH per Child below 5 years per year(UGX) 77,525 79,219 THECH per Child below 5 years per year ($) 40 39 Total Government Expenditure on health (Billions UGX) 450.290 472.610 Total Government expenditure CH (Billions UGX) 66.94 103.34 Total Government expenditure CH per child below 5 years(UGX)

13,340 18,224

Total Government expenditure CH per child below 5 years(US$)

6.9 9.0

Government expenditure on CH as a % of Total Government Health expenditure

15% 22%

Government expenditure on CH as a % of THECH 17% 23% Household expenditure on CH (Billions UGX) 245.716 277.351 Household expenditure on CH (Billions $) 0.13 0.14 Household expenditure on CH as a % of THECH 63% 62% ROW expenditure on CH as a % of THECH 27% 20% FINANCING SOURCES AS A % OF THECH: including HH Contribution

Public 4% 12%

Households 63% 62%

Private others 5% 6%

48

Indicators 2008/2009 2009/10 Donors and ROW 27% 20%

FINANCING AGENT DISTRIBUTION AS A % OF THECH:

Public 17% 23%

Households 63% 62%

Private (Others) 3% 3%

NGOs & ROW 16% 12%

PROVIDER DISTRIBUTION AS A % OF THECH: Public 24% 21%

PFP (FB) 42% 42%

PNFP (FB) 20% 19%

NGOs and ROW (NFB) 13% 17%

FUNCTION DISTRIBUTION AS A % OF THECH:

Inpatient curative care (CH services) 45% 44% Outpatient Curative Care( CH services) 32% 29% Pharmaceuticals and other non‐medical durables for CH 9% 8% Prevention and Public Health services(CH) 12% 16% Health care related functions( CH) 3% 2% Policy advocacy for Child health 0.2% 0.2%

6.3 Financing Sources of Child Health Care: Who Pays for Child Health Services?

Table 26 indicates that much of the funding for Child Health services in the two FYs was provided by the private sector; over 65% of Total Child Health expenditure for the two years. Public sources accounted for the least in the two financial years. Table 26: Sources of financing for CH FYs 2008/09 and 2009/10

FY2008/09 FY 2009/10 Amount in

Billions UGX % of Total

Amount in Billions % of Total

Public Funds 17.46 4% 52.19 12%Private Funds 267.04 69% 305.31 68%

ROW Funds 104.53 27% 91.68 20%

TOTAL 389.03 449.19

A significthe childpublic sepublic semanaged

Table 27: F

Public Se

Non‐Pub

TOTAL

Figure 13:

Househothan halfDistrict percentathrough

0

100

200

300

400

cant percentd health funector FY2008ector in FY d by the non

Financing agen

ector

lic Sector

Financing age

olds were a sf of the tothealth servage of Child Financing Ag

66.94

FY 2

tage of THECds managed8/09. There 2009/10 w

n‐public secto

nts for CH expe

FY 2008/AmountBillions U

66.94

320.86

387.80

nts for CH exp

significant ptal private fvices, whichHealth fundgents.

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320.86

2008/9(Billio

P

CHwas manad by the puwas a 6% in

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enditures – FY

/9t UGX %

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penditures – FY

layer in the unds spent h are the ss. Table 28,

6 (83%)

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49

aged by theublic sector ncrease in tan equal dle 27 below)

s 2008/09 – 20

% of Total

17%

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Ys 2008/09 – 2

managemeon CH servservice delivFigure 13 a

Non‐Pub

e non‐public and 83% wahe managemdecline in t)

009/10

FY 2009Amoun Billions

103.34

345.85

449.19

2009/10

nt of CH resvices in the very levels,nd Figure 14

103.34 (2

FY 2009/1

blic Sector

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9/10nts UGX %

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7

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50

Table 28: Detailed transfers through financing agents:

FY2008/09 FY2009/10 Public 17% 23%

Central level institutions 15% 21% District health service 2% 2%

Non‐Public/Private 83% 77% Households 63% 62%

NGOs 16% 12% Other private 3% 3%

Other private includes private health insurance and private practitioners

Figure 14: Detailed transfers through financing agents 2008/09




Ministry of Internal Affairs‐Uganda Prisons Services, 0.06%

Ministry of Internal Affairs‐Uganda Police

Services, 0.02%









Private firms OSF, 1.09%


51

Figure 15: Detailed transfers through financing agents 2009/10




Ministry of Internal Affairs‐Uganda Prisons Services, 0.04%

Ministry of Internal Affairs‐Uganda Police

Services, 0.09%











52

6.4 Child Health Expenditure by Providers: Who Uses Child Health Funds To Deliver Care?

There was a fair balance between expenditure by levels of care‐ hospitals versus lower level facilities for the two years of the study. Table 29 provides information on the providers of child health services. Table 29: Child Health expenditures by level of care FY2008/09 ‐ 2009/10

FY2008/09 FY2009/10 Amount Billions UGX % of Total


Hospital Level 144.35 37% 158.23 35% Lower Level 144.03 37% 163.31 36% Other Health Providers 100.66 26% 127.65 29%

TOTAL 389.04 449.18Other health providers include traditional healers, public health programmes, central management and research and training institutions.

6.5 Child Health Expenditure by Function: What Services Are Purchased With Child Health Funds?

Table 30 and Figure 16give the expenditure breakdown on Child Health expenditures by function. Much of the child health funds were used to purchase curative services 85% in FY2008/9, while 12% was used for preventive CH services. An increase of 8% in CH funds invested in preventive care in the subsequent financial year offset a reduction in curative CH services by 7%. Table 30: Child Health Expenditure by functions FYs 2008/9 ‐2009/10

FY2008/09 FY2009/10 Amount

Billions UGX % of Total Amount

Billions UGX % of Total

Curative functions 331.29 85% 365.14 78% Preventive functions 47.27 12% 94.04 20% Other Functions 10.47 3% 10.20 2% TOTAL 389.03 469.37 Other functions include health care related functions, addendum functions and health functions expenditures not specified by kind.

53

Figure 16: Child Health Expenditure by functions FYs 2008/9 ‐2009/10

6.6 Conclusions and recommendations 6.6.1 Conclusions

• Private sources play a significant role in financing CH services contributing over 65% of THECH. Significant players in private financing are HH contributing over 60% of private health expenditures on CH.

• The non – public sector is managing a significant percentage of CH expenditures over 75% of THECH for the two years

• Expenditure is predominantly on curative functions over 75% of THECH for the two years

6.6.2 Recommendations • Need to increase government investment in CH services • Address the decline in the share of the provision of prevention and public health

programs by increasing focus on preventive health care • Increase investment in prevention programmes

331.29 (85%)365.14 (78%)

47.27 (12%)

94.04 (20%)

0

50

100

150

200

250

300

350

400

FY2008/9(Billions UGX) FY2009/2010(Billions UGX)

Curative functions Preventive functions

54

7. Limitations of the Study Unavailability of quality expenditure data: Some non‐governmental and government institutions are reluctant to release information on their health spending. Record keeping seems to be a big challenge especially for the past years. Similarly inadequate data accessibility was encountered with international NGOs who have most of their health financing data kept at their country headquarters. Public Expenditure Classification (Chart of Accounts):Government budget and expenditure reports do not directly match the NHA expenditure data classifications. Therefore, where there were gaps, health service utilization reports from Health Management Information System and expert opinion from costing studies were used to disaggregate government expenditures on inpatient and outpatient services as well as to estimate government spending on medicines and sub accounts. Expenditure Overlaps:Some categories of expenditures overlap between Reproductive Health and Child Health such as PMTCT of HIV/AIDS, expenditure on management of new born, ITNs, Breast feeding counselling. Expert opinions were used to disaggregate these expenditures between the two sub accounts. Some estimates had to combine ‘ hard’ financial figures with ‘soft’ estimates to arrive at final expenditure estimations in some cases. Data not collected from a small number of NGOs and private employers:A small number of NGOs and private firms did not fill the questionnaire. The estimates collected were however weighted and the universal expenditure for those categories arrived at. It is also believed that some of the spending is reported by other institutions, but all this does not compensate for all the missed data, and it is believed that this could marginally underestimate spending from some these institutional summaries. Other contributions by community and in Kind:It is very common that other contributions are by communities, individuals, donors in‐ kind. The NHA estimates did not capture the community in kind contributions but it valued some of the in kind contributions by NGOs and Donors. Never the less the valuation of in‐kind contributions was a huge challenge to the NHA team because some in‐kind contribution could not have monetary value estimates in the Country. Funding Gaps:Due to financial constraints the NHA team could not cover large samples for some categories of institutions. However, to arrive at the universal category estimations, all samples were weighted.

55

8. Bibliography 1. A short guide to producing national health accounts, World Health Organization,

Regional Office for the Eastern Mediterranean Cairo, 2005. 2. BhawalkarManjiri, Susna De. April 2008; Reproductive Health, National Health Accounts 3. Framework for the Development and Institutionalization of National Health Accounts

(NHA) in the Pacific Islands. WHO, 2008. 4. HACA Bhavan, Hyderabad, AP ‐ 500 004, India. National Health Accounts Training

Manual for Implementing NHA in India, India 5. Health Sector Strategic Investment plan, 2010 6. National Health Accounts – Where Are We Today? SIDA Issue Paper by Catharina

Hjortsberg, 2001 7. National Health Accounts of Uganda, 1999/2001 8. National Health Accounts: Policy Brief on Concepts and Approaches; Regional Health

Forum WHO South‐East Asia Region Volume 7 Number 2, 2003. Dr U Than Sein; Dr Abdullah Waheed

9. Participant’s Manual. Bethesda, MD. Africa’s Health 2010 project and Health Systems 20/20 project, Abt Associates Inc.

10. Public health Expenditure management Review and National health Accounts 2005/06. 11. SHA Guidelines Practical guidance for implementing, A System of Health Accounts 2011:

the Office for National Statistics (UK) 12. The Global strategic action plan on NHA 2010. 13. The Country Cooperation Strategy Brief; World Health Organization 2009 14. Uganda Demographic Health survey ( UDHS 2009). 15. Synthesis of findings from NHA studies in Twenty –Six Countries, July 2004 Susna De et

al. 16. National technical paper to Guide data entry for National Health Accounts, Burkina Faso,

2005. 17. National Health Accounts plans for Ethiopia, Namibia, Kenya, Tanzania and Nigeria 2005. 18. The Country Cooperation Strategy Brief‐WHO 2009 19. World Health statistics 2012‐WHO 20. Commonwealth Health partnerships 2012 report 21. Fiscal Space for Health in Uganda 2009‐World Bank 22. Public Expenditure Review Reports (Uganda)‐2008‐2010. 23. Annual Health Expenditure reports , Ministry of Health 2008/09‐2009/10 24. Ministry of Finance, Planning and Economic Development –Annual reports 2008‐2010 25. Bank of Uganda ,Annual performance reports 2008‐2010 26. Ministry of Internal Affairs, Annual NGO board reports 2010 27. Final Accounts for all Government Institutions sampled for FY 2008/09 and 2009/10. 28. Annual reports from Non‐Government Organization’s and Donors 2008‐2010.

56

29. Statutory Instrument supplement – Insurance regulations, Government of Uganda gazette October 2002

30. Development cooperation report 2007‐2008, Ministry of Finance, Planning and Economic Development

31. Summary of project support managed outside government systems, Ministry of Finance, Planning and Economic Development‐2009

32. Annual Insurance market Report , Uganda insurance Commission 2007 33. Commission for Macroeconomics and Health, WHO, 2010 34. District Transfers for Health Services, Ministry of Health Kampala 2008/09 Financial Year

2009/10 35. Guidelines on the use of Conditional Grants for Lower Level NGO units from the Poverty

Action Fund. Ministry of Health Kampala, June 2009 36. Guidelines on the use of Primary Health Care Funds 2009/10‐Ministry of Health 37. Health Financing Strategy Volume II. Ministry of Health 2002 38. Ministry of Health 2010. Health Facilities Inventory, Kampala 39. Population Census Uganda Bureau of Statistics 2002 40. Poverty status report; MoFPED, 2010 41. Public Private Partnership in Health, 2012 42. The National Health Policy 11 Ministry of Health 2005 43. Uganda Demographic and Health Survey. Uganda Bureau of Statistics 2009 44. World Health Report 2010 45. Berman, P.A. (1997), National health accounts in developing countries: appropriate

methods and recent applications. Health Economics, 6, pp. 11‐30. 46. Bernard, J. and A. Tsui (1995), Indicators for reproductive health program evaluation.

Carolina Population Center, University of North Caroline, Chapel Hill. 47. De, Importance of NHA Subaccounts; and De and Hatt, "Reproductive and Child Health

Subaccounts to Track Resource Allocations and Flows." 48. De, Importance of NHA Subaccounts; and USAID, "Using Reproductive Health

Subaccounts to Advocate for Increased Resources for Family Planning," Repositioning in Action E‐Bulletin (August 2008), accessed at www.usaid.gov/our_work/global_health/pop/techareas/repositioning/repfp_ebulletin/080808_en.html, on January 4, 2010.

49. USAID (2009) "Using Reproductive Health Subaccounts to Advocate for Increased Resources for Family Planning"; and Health Systems 20/20 Project, "National Health Accounts Subaccounts: Tracking Health Expenditures to Meet the Millennium Development Goals," Project Brief.

50. PHRplus (2003) Understanding NHA: The Methodology and Implementation Process 51. Rannan‐Eliya, R. P., Berman, P., Eltigani, E.E., de Silva, I., Somanathan, A., Sumathiratne,

V (2000) Expenditures for Reproductive Health and Family Planning Services in Egypt and Sri Lanka. The POLICY Project, The Futures Group International, Inc

57

52. WHO (World Health Organization) (2003), Guide to producing national health accounts. With special applications for low‐income and middle‐income countries. WHO, Geneva. (available at http://whqlibdoc.who.int/publications/2003/9241546077.pdf).

53. NHA Training and implementation manual (Uganda) 2010 54. WHO Guide to Child Health and Reproductive Health Sub Accounts 2010. 55. WHO Guide for estimating Out Of Pocket Spending. 56. Health care financing profiles of East, Central and Southern African Health Community

countries 1995‐2011‐ECSA. 57. From Policy to Practice‐ Charles W.B. Matsiko‐MUK (25‐31). 58. Abolition of user fees: the Uganda paradox. Nabyonga Orem et al, 2011 59. Fiscal Space for Health in Uganda. Peter Okwero et al, May 2009

58

9. ANNEXES Annex 1: Glossary Financing Sources (FS) are entities that provide health funds. They answer the question “Where does the money come from?” Examples are ministries of finance, households, and donors. Financing Agents (HF) receives funds from financing sources and use the funds to pay for/purchase health care. Financing agents are important because they have programmatic responsibilities, i.e., they control how the funds are used. This category answers the question “Who manages and organizes the funds?” Examples are ministries of health and insurance companies. Providers (HP) are the end‐users of health care funds, i.e., the entities that deliver the health service. They represent the answer to the question, “Where does the money go?” Examples are private and public hospitals, clinics, and health care stations. Functions (HC) refer to the provider services for which health funds pay. Information at this level answers the question “What type of service was actually provided?” Examples are preventive, curative, and long‐term nursing care, administration of care facilities, and medical goods such as pharmaceuticals. Equity: Is defined as systems of justice based on conscience and fairness in health while equality is the condition of being equal. Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. It is achieved through the distribution of societal resources for health, including but not only through the actions of the health sector. Efficiency: The allocation of health resources in a manner which obtains the best value at least cost. NHA Institutionalization: Countries can be classified as having institutionalized NHA if they fulfill four simple criteria: (i) consistent government‐mandated production of a minimum set of NHA data; (ii) consistent use of NHA data; (iii) adequate financial, human, and infrastructure capacity for production and utilization of NHA data; and (iv) use of health accounts methodology in producing NHA data. NHA Entities: Institutions sampled to undertake the NHA survey. Fiscal Space: Capacity of gov’t to provide additional budgetary resources for a desired purpose without any prejudice to the sustainability of its financial position

59

Universal coverage of Health: Universal coverage of health care means that everyone in the population has access to appropriate promotive, preventive, curative and rehabilitative health care when they need it and at an affordable cost.1 Universal coverage thus implies equity of access and financial risk protection. Itis also based on the notion of equity in financing, i.e. that people contribute on the basis of ability to pay rather than according to whether they fall ill. This implies that a major source of health funding needs to come from prepaid and pooled contributions rather than from fees or charges levied once a person falls ill and accesses services. Development partner (DP): includes each and all of external Governments, bilateral agencies, multilateral agencies, funding foundations and global/regional health initiatives that are committed to working together and with the GOU in a joint effort to support the funding, whether in pooled or non‐pooled funding arrangements, and management of the implementation of the NDP/HSSIP and Annual Plans. Equity: Is defined as systems of justice based on conscience and fairness in health while equality is the condition of being equal. Equity in health implies addressing differences in health status that are unnecessary, avoidable and unfair. It is achieved through the distribution of societal resources for health, including but not only through the actions of the health sector.

Annex 2: Sources by Financing Agents, FY2008/9 (Billions UGX)

CODE

CODE FS.1 Public Funds FS.2 Private Funds FS.3 Rest of the World

FS.1.1.1 FS.1.1.2 FS.2.1 FS.2.2 FS.2.3 FS.2.4 FS.3.1 FS.3.2

FINANCING AGENTS MOF LGs Private Firms Households Foundation funds/NGOs

Other Private funds

Donors/HDPs International NGOs

Foundations

TOTAL % of total

HF.1.1.1 ‐ Central Government

HF.1.1.1.1 ‐ Ministry of Health 116.3096 19.2120 80.9279 216.4495 7.71%

HF 1.1.1.2 ‐ Ministry of Defence 4.4897 4.4897 0.16%

HF 1.1.1.3 ‐ Ministry of Education 0.3870 0.0123 0.9836 1.3830 0.05%

HF 1.1.1.4 ‐ Uganda Prisons Services 0.9242 0.1154 0.1162 1.1557 0.04%

HF 1.1.1.5 ‐ Uganda Police Services 1.7391 1.7391 0.06%HF 1.1.1.6 ‐ National Referral Hospitals 57.4194 4.8501 62.2695 2.22%

HF 1.1.1.7 ‐ Regional referral hospitals 47.8236 ‐ ‐ 0.3607 0.0103 ‐ 0.0020 0.3015 48.4982 1.73%HF 1.1.1.8 ‐ Other ministries 8.0550 7.9865 0.28%

HF 1.1.1.9 ‐ other National level Institutions 7.2953 1.2218 0.2154 83.1075 30.0117 121.8516 4.34%

HF.1.1.3 ‐ District Health Services 190.4098 5.4962 ‐ 3.7378 1.5202 ‐ 27.9353 16.0966 245.1957 8.73%

HF 2.5.1 ‐ Parastatals ‐ ‐ 0.00%

HF.B Private sector ‐ ‐ 0.00%

HF.2.2 ‐ Private Health Insurance ‐ 24.5740 2.9065 1.2886 0.4544 29.2236 1.04%

HF 2.3 ‐ Households ‐ 10.8720 1,200.9831 1,211.8550 43.14%

HF 2.4 ‐ Not for profit/NGO'S 9.6317 0.0021 2.9111 ‐ 74.3676 28.8597 466.2195 260.5751 842.5668 30.00%

HF 2.4.1 ‐ Not For Profit Facility based ‐ 0.00%

HF 2.4.2 ‐ Not for profit Non Facility based ‐ 0.00%

HF 2.5.2 ‐ Private Firms 14.0658 14.0658 0.50%

Total 444.4844 5.4982 52.4230 1,214.0600 95.4532 30.1483 658.3384 308.0848 2,808.7984 100.00%

% of Total 15.82% 0.20% 1.87% 43.22% 3.40% 1.07% 23.44% 10.97% 100.00%

61

Annex 3: Sources by Financing Agents Matrix, FY2009/10 (Billions UGX) CODE

CODE FS.1 Public Funds FS.2 Private Funds FS.3 Rest of the World

FS.1.1.1 FS.1.1.2 FS.2.1 FS.2.2 FS.2.3 FS.2.4 FS.3 FS.3.1 FS.3.2

FINANCING AGENTS MOF LGs Private Firms

Households Foundation funds/NGOs

Other Private funds

ROW Donors/HDPs International NGOs

Foundations

TOTAL % of Total

HF.1.1.1 ‐ Central Government

HF.1.1.1.1 ‐ Ministry of Health 62.1785 1.5177 ‐ ‐ 63.6962 1.97%

HF 1.1.1.2 ‐ Ministry of Defence 3.6776 ‐ ‐ ‐ 3.6776 0.11%

HF 1.1.1.3 ‐ Ministry of Education 1.6982 0.0084 ‐ 0.0635 1.7701 0.05%

HF 1.1.1.4 ‐ Uganda Prisons Services 0.8476 0.3003 0.0345 0.0914 1.2739 0.04%

HF 1.1.1.5 ‐ Uganda Police Services 2.2112 ‐ ‐ 2.2112 0.07%

HF 1.1.1.6 ‐ National Referral Hospitals

47.3687 4.0893 ‐ 51.4580 1.59%

HF 1.1.1.7 ‐ Regional referral hospitals

49.7694 ‐ ‐ 0.4303 0.0021 ‐ ‐ 0.0063 0.2649 50.4731 1.56%

HF 1.1.1.8 ‐ Other ministries 7.4099 131.3558 138.7657 4.29%

HF 1.1.1.9 ‐ other National level Institutions

91.4933 2.2571 6.1505 23.8912 12.1384 135.9306 4.20%

HF.1.1.3 ‐ District Health Services 197.4261 2.5557 ‐ 5.2709 2.4184 ‐ ‐ 20.5906 18.7689 247.0307 7.64%

HF.2.2 ‐ Private Health Insurance 34.5964 3.0113 0.8886 0.4693 38.9657 1.20%

HF 2.3 ‐ Households 11.6160 1,356.7510 1,368.3670 42.30%

HF 2.4 ‐ Not for profit/NGO'S 5.6096 0.1003 6.3732 ‐ 90.4576 34.8726 ‐ 675.5855 307.6790 1,120.6779 34.64%

HF 2.5.2 ‐ Private Firms 10.6485 10.6485 0.33%

Total

469.6902 2.6561 63.2340 1,371.8100 100.8550 35.7612 ‐ 851.9333 339.0062 3,234.9461 100.00%

% of Total

14.52% 0.08% 1.95% 42.41% 3.12% 1.11% 0.00% 26.34% 10.48% 100.00%

62

Annex 4: Financing Agents by Provider Matrix, FY2008/9 (Billions UGX) HF.1.1.1.1 HF

1.1.1.2 HF 1.1.1.3

HF 1.1.1.4

HF 1.1.1.5

HF 1.1.1.6

HF 1.1.1.7

HF 1.1.1.8

HF 1.1.1.9 HF.1.1.3 HF.2.2 HF 2.3 HF 2.4 HF 2.5.2

CODE HEALTH PROVIDER

Ministry of Health

Ministry of Defense

Ministry of Education

Ministry of Internal Affairs‐Uganda Prisons Services

Ministry of Internal Affairs‐Uganda Police Services

National Referral Hospitals

Regional referral hospitals

Other ministries

other National level Institutions

District Health Services

Private Health Insurance

Households

Not for profit/NGO'S

Private Firms

Total % of Total

HP.1 Hospitals

HP.1.1.1 Government owned Hospitals

‐ 4.4897 1.1557 ‐ ‐ ‐ 0.0273 ‐ 5.6727 0.20%

HP.1.1.1.1 National Referral Hospital

‐ 62.2695 ‐ ‐ ‐ 0.0390 4.8827 19.2690 86.4603 3.08%

HP.1.1.1.2 Regional Referral Hospital

‐ 48.4982 ‐ ‐ ‐ 0.3607 35.9005 84.7594 3.02%

HP.1.1.1.3 General Hospitals

‐ 7.4820 ‐ 8.3873 3.7378 58.2960 77.9031 2.77%

HP.1.1.2 Private Hospitals

HP.1.1.2.1 PNFP Hospitals

‐ ‐ ‐ 20.0046 1.2978 189.6245 18.5667 229.4936 8.17%

HP.1.1.2.2 PFP Hospitals

‐ ‐ ‐ ‐ 27.2987 229.6585 256.9571 9.15%

HP.3.4.9.1 Government lower level units

‐ ‐ 154.9559

59.2458 214.2017 7.63%

HP.3.4.9.2 PNFP lower levels of care

‐ 0.0508 ‐ ‐ 97.3770 7.2451 104.6730 3.73%

HP.3.4.9.3 Private for profit Clinic

13.1307 ‐ 0.3450 ‐ 0.2168 646.9376 2.6306 5.3814 668.6422 23.81%

63

HF.1.1.1.1 HF 1.1.1.2

HF 1.1.1.3

HF 1.1.1.4

HF 1.1.1.5

HF 1.1.1.6

HF 1.1.1.7

HF 1.1.1.8

HF 1.1.1.9 HF.1.1.3 HF.2.2 HF 2.3 HF 2.4 HF 2.5.2


Ministry of Health

Ministry of Defense






Other ministries




Households


Private Firms

Total % of Total

and Drug shops

HP.3.4.9.4 All other OPD community and other integrated care centres

‐ 1.7391 ‐ 0.0138 53.0515 33.8501 1.2700 89.9245 3.20%

HP.3.9.3 Traditional healers

0.0685 0.4537 ‐ 4.2043 5.8883 10.6148 0.38%

HP.5 Provision and administration of public health programmes

‐ 1.3830 ‐ 103.2037 ‐ 0.3440 1.2218 591.6159 697.7683 24.84%

HP.5.2 Blood services

‐ ‐ 7.6999 ‐ ‐ 7.6999 0.27%

HP.6.1.1 Central MoH HQ

‐ ‐ 6.4718 ‐ 18.9666 25.4384 0.91%

HP.6.1.2 District health office

‐ ‐ 8.7964 ‐ 8.7964 0.31%

HP.7.3 On‐site facilities to providers

‐ ‐ ‐ ‐ ‐ 7.5984 7.5984 0.27%

HP.8.1 Research Institutions

203.3188 ‐ ‐ ‐ 19.9042 223.2230 7.95%

HP.8.2 Training ‐ ‐ ‐ ‐ 2.3212 2.3212 0.08%

64

HF.1.1.1.1 HF 1.1.1.2

HF 1.1.1.3

HF 1.1.1.4

HF 1.1.1.5

HF 1.1.1.6

HF 1.1.1.7

HF 1.1.1.8

HF 1.1.1.9 HF.1.1.3 HF.2.2 HF 2.3 HF 2.4 HF 2.5.2


Ministry of Health

Ministry of Defense






Other ministries




Households


Private Firms

Total % of Total

Institutions

HP.8.3 Institutions providing health related services

‐ ‐ 2.1223 ‐ ‐ 2.1223 0.08%

HP.nsk 1.9952 ‐ ‐ ‐ 1.4468 1.0860 4.5279 0.16%

Total 218.5131 4.4897 1.3830 1.1557 1.7391 62.2695 48.4982 7.9865 119.8565 245.1957

29.2236 1,211.8550

842.5668 14.0658

2,808.7984 100.0%

% of total 7.78% 0.16% 0.05% 0.04% 0.06% 2.22% 1.73% 0.28% 4.27% 8.73% 1.04% 43.14% 30.00% 0.50% 100.00%

65

Annex 5: Financing Agents by Provider Matrix, FY2009/10 (Billions UGX) HF.1.1.1.1 HF

1.1.1.2

HF 1.1.1.3

HF 1.1.1.4

HF 1.1.1.5

HF 1.1.1.6

HF 1.1.1.7

HF 1.1.1.8

HF 1.1.1.9

HF.1.1.3

HF.2.2 HF 2.3 HF 2.4 HF 2.5.2


Ministry of Health

Ministry of Defence






Other ministries




Households


Private Firms

Total % of Total

HP.1 Hospitals


3.6776

1.2739 0.0000 0.0000 0.0860 1.2273 6.2648 0.19%

HP.1.1.1.1

National Referral Hospital

36.6602 0.0000 0.0000 0.0576 4.1242 10.1203 50.9623

1.58%

HP.1.1.1.2

Regional Referral Hospital

50.4731

0.0000 0.0000 0.4303 28.6229 79.5262

2.46%

HP.1.1.1.3

General Hospitals

6.7520

0.0000 8.2411 5.2709 86.9874 107.2514

3.32%

HP.1.2 Mental Health Hospitals

13.1968 0.0000 0.0000 9.7662 22.9631

0.71%


0.0000 0.0000 0.0000 0.00%

HP.1.1.2.1

PNFP Hospitals 0.0000 22.6052 1.2102 261.8618 18.1420 303.8192

9.39%

HP.1.1.2.2

PFP Hospitals 0.0000 0.0000 36.8554 258.8125 295.6679

9.14%

HP.3.4.9.1

Government lower level units

3.1588 2.2112 168.0662

64.1256 237.5618

7.34%

HP.3.4.9.2

PNFP lower levels of care

0.0000 36.9352 96.9108 7.7564 141.6023

4.38%

HP.3.4.9.3

Private for profit Clinic and

0.6579

0.4418 0.0000 0.2843 730.8410 9.1014 2.1278 743.4543

22.98%

66

Drug shops

HP.3.4.9. All other OPD community and other integrated care centres

0.0000 0.0000 3.6669 3.6443 7.3111 0.23%

HP.3.9.3 Traditional healers

0.0000 4.1914 1.2514 5.4428 0.17%

HP.5 Provision and administration of public health programmes

105.4020

0.0000 0.4691 2.2571 323.6478 431.7760

13.35%

HP.5.2 Blood services 9.9267 0.0000 8.4131 18.3397

0.57%

HP.6.1.1 Central MoH HQ

191.8932 14.2832 0.0000 18.4856 224.6619

6.94%

HP.6.1.2 District health office

11.1830 11.1830

0.35%

HP.7.3 On‐site facilities to providers

0.0000 0.0000 0.0000 7.8678 7.8678 0.24%

HP.8.1 Research Institutions

1.6010 3.3174 0.0000 44.5732 49.4916

1.53%

HP.8.2 Training Institutions

1.7701 0.0000 0.0000 2.3443 4.1144 0.13%

HP.8.3 Institutions providing health related services

2.5595 0.0000 482.4688 485.0283

14.99%

HP.nsk 0.0000 0.0030 0.0000 0.6529 0.6559 0.02%

Total

195.0520 3.6776

1.7701 1.2739 2.2112 51.4580 50.4731

7.4099

135.9306

247.0307

38.9657 1368.3670

1120.6779 10.6485 3234.9461

100.0%

% of total

6.03% 0.11% 0.05% 0.04% 0.07% 1.59% 1.56% 0.23%

4.20% 7.64% 1.20% 42.30% 34.64% 0.33% 100.00%

67

Annex 6: Provider by Function Matrix, FY2008/9 (Billions UGX) CODE HP.1 Hospitals

CODE HEALTH FUNCTION

HP.1.1.1 Government owned Hospitals HP.1.1.2 Private owned Hospitals

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2 HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.4

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3 HP.8.1 HP.8.2 HP.8.3 HP.nsk

National Referr al Hospit al

Regional Referr al Hospit al

Gener al Hospitals

Ment al Health Hospitals

PNFP Hospitals

PFP Hospitals



Private for profit Clinic and Drug shops

All other OPD community and other integrated care centres

Traditional healers

Provision and administration of public health programmes‐NGOs

Blood services

Central MoH HQ

District health office

On‐site facilities to providers

Research Institutions

Training Institutions

Institutions providing health related services

Total

HC.1 Services of Curative Care

0.0000

HC.1.1

Inpatient Curative Care

13.2872

8.2836 5.0965 0.0000 197.5629

242.0500

39.8934 15.4852

0.0138 60.1670 0.0000

2.4537 0.0000

584.2934

20.80%

HC.1.3

Outpatient curative care

4.6934 5.2819 3.3024 0.0000 91.7956

6.4247 29.3888 658.6150

0.0911 33.8501 117.8904 0.0000

2.3020 0.0000

3.5161 957.1515

34.08%

HC.1.4

Services of Curative home Care

0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

0.1676 0.0000

0.1676 0.01%

HC.2 Services of Rehabilitative Care

0.1122 0.0000 0.0000 0.0000 0.0342 0.1302 0.0000 0.0000 0.0000 0.0000 0.0000

0.5770 0.0000

0.8537 0.03%

HC.4 Ancilliary Services to Health Care

HC.4.1

Clinical Laboratory

2.8254 2.7536 0.2039 0.0000 0.4539 0.7379 2.8280 0.2790 0.0000 0.0000 0.0000 0.0000 1.4468

2.1346 0.0000

0.0000 0.0000 0.0000 0.0000 0.0000

6.3345 0.23%

HC.4.2

Diagnostic imaging

0.0594 0.0000 0.0000 0.0000 0.0254 0.3203 0.0000 0.0000 0.0000 0.0000 0.0000

3.0259 0.0000

3.4311 0.12%

HC.4.3

Patient transport/Emergency rescue

0.0119 0.0000 0.0000 0.0000 0.0288 0.0676 0.0000 0.0000 0.0000 0.6697 1.3080

0.0000 0.4398

2.5258 0.09%

HC.4.9

All other Miscellaneous ancillary services

0.0132 0.0000 3.6017 6.7256 0.6721 0.1609 0.0000 1.6360 0.0000 0.0000 0.1919

0.0000 0.0000

13.0015

0.46%

HC.5 Medical Goods Dispensed to Outpatients

HC.5.1

Pharmaceuticals and other Medical non‐Durables

7.4372 16.3113

8.8800 0.0000 1.4552 3.3944 2.0579 1.4150 0.1257 0.0000 0.0000 82.1948 0.0000

76.3611

0.0000

0.0000 0.0000 0.0000 0.0000 0.0000

199.6327

7.11%

HC.5.1.1‐2

Pharmaceuticals (prescribed and over‐the‐

10.0529

3.1180 0.0000 3.4323 0.0000 0.0000 0.0993 0.0000 4.1208

0.2728 0.8796

21.9756

0.78%

68

counter)

HC.5.1.3

Other medical non‐durables

0.1691 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0724 0.1122

0.1565 0.0000

0.5102 0.02%

HC.5.2 Therapeutic Appliances and other medical durables

0.2914 0.0000 0.0000 0.0000 0.0768 0.0342 0.0000 0.0000 0.0000 0.0000 0.0000

8.3803 0.0000

8.7827 0.31%

HC.6 Prevention and Public Health Services (outreach)

0.0062 0.9394 6.9249 0.0000 2.6833 1.9777 12.5401 2.2937 1.7888 0.0000 0.0000

6.2849 0.0000

2.3440 37.7830

1.35%

HC.6.1 Maternal and child health; family planning and counselling

8.8367 6.2581 15.0759

4.9400 1.2831 0.5706 8.6502 1.9615 0.0000 0.0000 0.0000

2.3920 0.0000

49.9682

1.78%

HC.6.2 School health services

0.5803 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

0.6020 0.4398

1.6222 0.06%

HC.6.3 Prevention of communicable diseases (e.g. HIV/AIDS, malaria)

8.3428 12.8151

17.4661

20.6620

7.3761 0.9446 12.9030 20.7145

2.6306 0.5082 353.6713 0.0000

58.5322

0.8796

517.4463

18.42%

HC.6.4 Prevention of non‐communicable diseases

1.1076 0.5273 0.0000 0.3123 0.0697 0.0000 0.0000 0.0000 0.0000 0.0000

0.3121 0.8796

3.2087 0.11%

HC.6.5 Occupational Health care

0.5803 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

0.1166 0.8796

1.5765 0.06%

HC.6.6 Monitoring and Evaluation

0.6098 0.0000 2.0219 0.0000 0.3425 0.0000 0.0000 0.0000 2.1637 0.0000

0.8773 0.8796

6.8947 0.25%

HC.6.9 All other miscellaneous public health services

0.7468 0.0000 5.5719 0.1325 0.0000 0.0000 0.0000 0.3440 0.0000

13.6549

0.8796

21.3297

0.76%

HC.7 Health Administration and Health Insurance

11.3402

7.9229 0.3355 0.0000 6.8662 0.1439 35.5667 3.5949 0.8672 0.5179 77.4776 0.9964

0.0000 0.8796

146.5092

5.22%

HC.7.1 Gov't Admin of Health

0.5803 0.0000 3.5342 6.1837 0.3592 0.0000 0.0000 0.0000 0.0000

0.0000 0.8796

11.5371

0.41%

HC.7.2 Admin of Health Insurance

0.5803 0.0000 0.0000 0.0000 1.6659 0.0000 0.0000 0.0000 0.0000 0.0000

0.0000 0.8796

3.1259 0.11%

HC.nsk HC expenditure not specified by any kind

0.5803 0.0000 3.0672 0.0000 0.4349 10.3284

0.0000 0.0000 0.0312 0.0000 10.0926 0.0000 0.0000

0.5850 0.0000

1.0860

26.2055

0.93%

HCR. Health Care Related

0.5803 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

0.0000 0.0000

0.5803 0.02%

HCR.1 Capital formation for health care provider

10.5948

15.0264

1.0904 2.1982 2.6006 49.9438 0.0000 0.0862 1.2475 0.9362

27.1447

0.0000

1.7383 2.1223 114.7294

4.08%

69

institutions

HCR.2 (Formal) Education and Training of Health Personnel

2.9597 2.3250 0.1957 5.8640 0.0000 0.0000 0.0000 1.8700 0.0343

1.2764 0.0000

2.3212 16.8462

0.60%

HCR.3 Research and development in health

1.6152 0.9178 0.0000 0.1859 0.0000 0.0000 0.0000 0.0000 0.0000

0.3432 0.0000

21.8994 24.9615

0.89%

HCR.4 Food, hygiene and drinking water control

0.8039 0.0000 1.5350 0.0000 0.0112 0.0000 0.0000 0.0000 0.0000 0.0000

14.1893

0.0000

16.5395

0.59%

HCR.5 Environmental Health

0.6145 0.0000 0.0000 0.0000 0.3013 0.0000 0.0086 0.0000 0.0000

0.1432 0.0000

1.0676 0.04%

HCR.nsk

HCR expenditure not specified by any kind

0.5803 0.0000 0.0000 0.2781 0.0000 0.0196 0.0000 0.0000

0.0000 0.0000

0.8780 0.03%

Total 90.5940

82.4804

77.9031

50.9146

315.4384

267.2855

194.4324 705.9948

3.7654 36.8730 10.0926 697.7683 9.1466

222.2854

8.7964

7.5984 21.8994 2.3212 2.1223 1.0860

2808.7984

100.0%

% of total 3.23% 2.94% 2.77% 1.81% 11.23% 9.52% 6.92% 25.14% 0.13% 1.31% 0.36% 24.84% 0.33%

7.91% 0.31% 0.27% 0.78% 0.08% 0.08% 0.04%

100.00%

70

Annex 7: Provider by Function Matrix, FY2009/10 (Billions UGX) HP.1.1.1 Government owned

Hospitals HP.1.1.2 Private Hospitals

CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals

Mental Health Hospitals

PNFP Hospitals

PFP Hospitals




Community and centres5

Traditional healers

Provision and admin‐NGOs/CBO6

s

Blood services

Central MoH HQ





Institutions providing health related svs

Total % of total

HC.1

Services of Curative Care

HC.1.1

Inpatient Curative Care

14.0673

4.2336

25.5489

1.2737

161.3825

275.3440

24.7911

58.1465

295.8451

3.6669

4.1914

23.2773

‐

‐

1.1183

‐

‐

1.8930

894.7796

27.66%

HC.1.3

Outpatient curative care

3.7090

1.6515

3.7168

0.9876

107.4780

8.8008

24.6554

52.1824

429.3047

1.7042

15.6576

‐

‐

‐

3.6777

‐

‐

‐

653.5258

20.20%

HC.1.4

Services of Curative home Care

‐

‐

‐

‐

‐

‐

3.6997

‐

‐

1.1183

‐

‐

‐

4.8180

0.15%

HC. Service 0.06

5All other community and other integrated care centres 6Provision and administration of public health programmes-NGOs/CBO

71



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

2 s of Rehabilitative Care

‐ ‐ 0.3422

0.0113

0.0154

‐ ‐ 1.4719

‐ ‐ ‐ ‐ ‐ ‐ 1.8409 %

HC.3

Services of long term nursing Care

‐

‐

‐

‐

‐

‐

3.6997

‐

‐

‐

‐

‐

‐

3.6997

0.11%

HC.4

Ancilliary Services to Health Care

HC.4.1

Clinical Laboratory

0.5590

0.5169

0.1648

0.0897

0.3824

0.0637

0.0745

‐

0.0177

‐

‐

9.7169

‐

0.0535

1.1183

‐

‐

‐

9.7662

‐

22.5237

0.70%

HC.4.2

Diagnostic imaging

2.0656

1.9446

‐

‐

0.0447

0.0671

‐

‐

0.0118

‐

1.8061

‐

8.3803

‐

‐

‐

14.3201

0.44%

72



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

HC.4.3

Patient transport/Emergency rescue

0.0453

‐

‐

0.0690

0.0279

1.9082

‐

‐

6.4852

1.5145

‐

1.1183

‐

‐

‐

11.1683

0.35%

HC.4.9

All other Miscellaneous ancillary services

‐

1.0713

0.1129

1.3563

3.0317

0.7387

‐

‐

0.6740

‐

1.1183

‐

‐

14.7128

22.8160

0.71%

HC.5

Medical Goods Dispensed to Outpatients

HC.5.1

Pharmaceuticals and

13.7007

4.3658

0.4945

1.0020

4.6341

5.3459

8.6624

1.5485

0.0499

‐

95.4452

‐

‐

1.1183

‐

‐

‐

136.3674

4.22%

73



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

other Medical non‐Durables

HC.5.1.1‐2

Pharmaceuticals (prescribed and over‐the‐counter)

3.2218

0.7918

‐

0.4134

0.1121

‐

‐

‐

4.6906

23.6552

1.1183

‐

‐

‐

34.0032

1.05%

HC.5.1.3

Other medical non‐durables

0.2250

‐

‐

0.2044

‐

‐

‐

0.1642

0.2082

0.4427

‐

‐

‐

‐

1.2446

0.04%

HC.5.2

Therapeutic Appliances

0.0925

0.1794

‐

0.1529

0.1288

0.1261

‐

0.0124

‐

‐

‐

0.5520

‐

‐

‐

‐

1.2442

0.04%

74



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

and other medical durables

HC.6

Prevention and Public Health Services (outreach)

0.0967

0.6346

‐

0.1879

0.1229

2.9200

33.1760

‐

‐

0.5504

‐

‐

‐

2.4518

‐

‐

‐

40.1404

1.24%

HC.6.1

Maternal and child health; family planning and counse

7.1381

2.9095

29.8464

1.5054

3.3771

0.0685

20.8989

2.9076

3.7918

‐

86.2297

‐

20.8889

‐

‐

‐

‐

179.5620

5.55%

75



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

lling

HC.6.2

School health services

0.0220

‐

0.0113

0.4081

‐

‐

2.6353

‐

0.1241

‐

‐

‐

‐

3.2008

0.10%

HC.6.3

Prevention of communicable diseases (e.g. HIV/AIDS, malaria)

10.5550

5.6527

20.9446

0.9316

6.5813

2.1623

11.3932

5.7636

1.8342

1.9400

248.0060

‐

120.4423

‐

‐

‐

‐

436.2069

13.48%

HC.6.4

Prevention of non‐communicable diseas

0.4531

‐

1.6988

1.0353

1.3905

0.0132

‐

‐

23.3374

‐

0.0431

‐

‐

‐

‐

27.9714

0.86%

76



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

es

HC.6.5

Occupational Health care

0.1913

‐

0.0433

0.0219

‐

‐

‐

‐

0.0543

1.1183

‐

‐

‐

1.4290

0.04%

HC.6.6

Monitoring and Evaluation

1.4343

1.5612

‐

0.0543

0.1199

‐

‐

11.8363

‐

1.6313

1.1183

‐

‐

‐

17.7555

0.55%

HC.6.9

All other miscellaneous public health services

‐

‐

‐

60.0859

‐

‐

‐

8.4131

‐

‐

‐

‐

‐

68.4990

2.12%

HC.7

Health Administration and Health

77



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

Insurance

HC.7.1

Gov't Admin of Health

16.3141

3.8531

2.2746

2.5000

7.5897

0.3462

18.4332

20.2483

1.0127

‐

‐

289.3232

1.2082

5.9841

‐

‐

‐

‐

‐

‐

369.0874

11.41%

HC.7.3

General Health Administration

6.2475

5.6405

5.9660

4.4935

6.9877

11.0352

15.0640

‐

2.2964

1.2514

‐

‐

0.0999

‐

‐

‐

‐

0.6529

59.7350

1.85%

HCR.

Health Care Related

HCR.1

Capital formation for health care provider institut

6.1849

8.5156

12.6329

7.7570

4.8712

7.8514

0.0666

‐

14.4411

1.5773

26.4014

1.1183

1.7383

‐

‐

‐

93.1562

2.88%

78



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

ions

HCR.2

(Formal) Education and Training of Health Personnel

0.1398

‐

‐

0.0721

‐

‐

‐

12.8519

0.0538

1.0940

‐

‐

4.1144

‐

18.3260

0.57%

HCR.3

Research and development in health

1.6010

0.3075

‐

‐

‐

‐

‐

44.5875

‐

0.1101

‐

47.8906

‐

‐

0.0030

94.4997

2.92%

HCR.4

Food, hygiene and drinking water

‐

‐

‐

0.0008

0.2160

6.6440

‐

‐

14.6098

‐

‐

‐

‐

‐

‐

21.4707

0.66%

79



CODE

HEALTH FUNCTION

HP.1.1.1.1

HP.1.1.1.2

HP.1.1.1.3

HP.1.2

HP.1.1.2.1

HP.1.1.2.2

HP.3.4.9.1

HP.3.4.9.2

HP.3.4.9.3

HP.3.4.9.

HP.3.9.3

HP.5 HP.5.2

HP.6.1.1

HP.6.1.2

HP.7.3

HP.8.1

HP.8.2

HP.8.3 HP.nsk



General Hospitals


PNFP Hospitals

PFP Hospitals





Traditional healers


s

Blood services

Central MoH HQ






Total % of total

control

HCR.5

Environmental Health

‐

‐

‐

0.0752

‐

‐

1.0577

‐

0.4215

‐

‐

‐

‐

1.5544

0.05%

Total 87.4858

42.9060

104.3597

22.9631

306.3106

306.7031

237.5618

141.6023

734.1768

3.6443

5.4428

910.8903

18.3397

210.3787

11.1830

7.8678

47.8906

4.1144

26.3721

0.6559

3,234.9461

100.00%

% of total

2.70% 1.33%

3.23% 0.71%

9.47% 9.48% 7.34% 4.38% 22.70% 0.11% 0.17%

28.16%

0.57%

6.50% 0.35% 0.24%

1.48%

0.13%

0.82% 0.02%

100.00%

NATIONAL HEALTH ACCOUNTS FY 2008/09 and FY 2009/10health.go.ug/docs/NHA_REPORT_FINAL_13.pdfthe...

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